Confidential
The Hong Kong Tuberculosis, Chest and Heart Diseases Association
Peggy Lam Health Promotion and Education Centre
Address: G/F., 266 Queen’s Road East, Wan Chai.
Tel: 2834 9333
Fax: 2834 5522
Email: hpc@antitb.org.hk
Membership Application/ Renewal Form
Please fill in with block letters and “” where appropriate. Please refer the membership regulations to the back page.
Application category:
 New membership
Official Use Only
 Renewal
Fee: __________
 Cash  Cheque___________
Part A: Personal Information
Name in Chinese
Name in English
First name
Age
Date of Birth
Last name
Gender
Day / Month / Year
Occupation
 Nurse
 Housewife
Tel
 Retired
 Student
 Others (
)
Email
Mailing Address
Part B: Organisation Information (Only for application of institutional member)
Name in Chinese
Name in English
Contact Person
Position
Membership category and fee
 Life member
HK$600
 Senior (aged 65 or aboeve) / student
HK$50
 Ordinary member
HK$100
 Institutional member
HK$300
I understand that the personal data provided by me are mainly for use within the Hong Kong Tuberculosis, Chest and Heart
Association - Peggy Lam Health Promotion and Education Centre. The information provided herein will only disclose to
parties where I have given consent to such disclosure or where such disclosure is allowed under the Personal Data (Privacy)
Ordinance.
Signature of applicant
Date
Organisation Chop (Only for application of institutional member)
Approval (For official use)
Approved by: ___________________________ (Executive Secretary)
Signature
Receipt No.: ____________________________
Date: ______________________________
Membership No.: ____________________________
Temporary Receipt (For official use)
Official receipt and membership card will be sent by mail to applicant after approval
Received date: _______________________ Fee: _____________
 Cash
 Cheque _________________________
Name of applicant: _____________________ Checked by (Staff signature and Centre chop): ________________________
Membership Regulations
A. Membership regulations
1. Applicant of student member should be aged 21 or below and must be a full-time student.
2. The expiry date of all kinds of memberships is on 31st December of the year of application.
(Except for Life member)
3. For institutional member, a maximum of 3 persons can enjoy the member benefits at one time.
4. Membership fee is not refundable. (Except for those applications rejected by the Centre)
5. Members would enjoy special rates for the Centre activities.
6. Members would receive the newsletter of the Association and information of the Centre
activities.
B. Methods of application
1. In person: Please submit the completed application form with membership fee to the Centre
during the opening hours, i.e. 9:00 a.m. - 12:30 p.m. and 2:00 p.m. - 5:00 p.m. For the
application of senior and student member, please show your ID card/ student card to the staff for
checking.
2. By mail: Please return the completed application form with a crossed cheque payable to “The
Hong Kong Tuberculosis, Chest and Heart Diseases Association” to the Centre. For the
application of senior and student member, please send with a copy of your ID card/ student card
to the Centre for checking. Cash is not accepted by mail. Address: 266 Queen’s Road East,
Wan Chai, Hong Kong
**The above regulations are subject to change without any prior notice.