Year 2007 - Critical Success Factors

Membership Appl i cat ion Form FULL MEMBER / INDIVIDUAL MEMBER / INDIVIDUAL ASSOCIATE MEMBER Please complete and mail this form together with your payment to: Director of Membership Extension, GPO Box 6542, Hong Kong. Website : www.hkcii.org Type of Membership Applied (Please refer to the membership definition stated below before completion) □ Full Member Please complete Section 1 and Section 2, and refer to the notes stated below. □ Individual Member □ Individual Associate Member } Please complete Section 2 only. Section 1 - Full Member (Entrance Fee: HK$1,000; Annual Subscription: HK$500) Name of Company : Company Address : Tel : Fax : E-mail : Business Registration No. : Year Established : We are registered agent / authorised broker in compliance with the law of Hong Kong. Main line of business: General / Life / Composite Insurance Appointed Nominee : (Please also complete Section 2 to become an Individual Member.) Please enclose a copy of your Business Registration Document with this application for our records. Section 2 - Individual Member (Entrance Fee: HK$200; Annual Subscription: HK$100) or Individual Associate Member (Entrance Fee: HK$200; Annual Subscription: HK$100) Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Name of company : Correspondence address : Tel : Fax : E-mail : I am a registered agent / authorised broker in compliance with the law of Hong Kong. Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : My main line of business : General / Life / Composite Insurance Others : I/We, the undersigned hereby apply for admission to become Full Member / Individual Member / Individual Associate Member of the Hong Kong Chamber of Insurance Intermediaries and agree to comply with all the regulations as set by the Chamber from time to time. I/We understand that the acceptance of my /our application is subject to the final approval of the Executive Committee of the Chamber. My / Our membership fee made payable to Hong Kong Chamber of Insurance Intermediaries is herewith enclosed as follows : Bank name : Cheque number : Amount (HK$) : Signature of applicant (With company chop where appropriate) Proposer : Name : Date : Note: “ Full Member ” - is an organisation who carries on business in Hong Kong as an insurance intermediary under a valid business registration certificate issued by Hong Kong S.A.R. Government and is to be represented by a Nominee of such organisation registered with the Chamber and duly accepted by the Chamber. (A “Nominee” is an Individual Member of the Chamber who is the chief or a very senior executive officer of, and nominated by a Full Member.) Total membership fee for Full Member: HK$1,800.00. “ Individual Member ” - is an insurance intermediary who represents himself in person in the Chamber and duly accepted by the Chamber. “ Individual Associate Member ” - is a person whose business activities are closely related to the insurance industry and duly accepted by the Chamber. Please tick this box if you do not want your personal details to be made available to the public. For office use only Date received : Date ack. sent : Membership No. Assigned Date approved : Date cert sent : Full Membership due date : Individual Remarks : Ind. Associates