Year 2007 - Critical Success Factors

Membership No. Assigned Company Nominee 1 Nominee 2 Nominee 3 Nominee 4 Nominee 5 Membership Appl i cat ion Form C O R P O R A T E A S S O C I A T E M E M B E R Please complete and mail this form together with your payment to: Director of Membership Extension, GPO Box 6542, Hong Kong. Website : www.hkcii.org Corporate Associate Member (Entrance Fee HK$1,000. Annual Subscription Fee HK$500) Name of Company : Company Address : Tel : Fax : E-mail : Main line of business : General/Life/Composite Insurance Others : Name of Nominee(s) Corporate Associate Membership is entitled to nominate an unlimited number of nominees. All correspondence will be forwarded to nominee 1) 1 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 2 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 3 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 4 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : 5 Name : Mr / Mrs / Miss : Name in Chinese (if any): Date of birth : Nationality : Passport / ID number : Position Held : Experience in insurance field: since (year) : Insurance qualification (if any): ( )FCII ( )ACII ( )ANZIIF ( )FLMI ( )CLU Others: (please specify) : We, the undersigned hereby apply to become Corporate 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. We understand that the acceptance of our application is subject to the final approval of the Executive Committee of the Chamber. 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: Corporate Associate Member is an organisation 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 : Date approved : Date cert sent : Membership due date : Remarks :