Name:                                                                     Sex: 

  IC No:                                                                     Date of Birth: 

  Home Address: 

  Home Telephone no::                                             e-mail: 

  Workplace Address: 
 

  Workplace Telephone no: 

  Command of languages 
                                       Written                                  Spoken  

  Malay 

  Chinese 

  Tamil 

  English 

  Others 

  Occupation: 

  Membership in political parties/trade unions/voluntary bodies: 
 

  Social issues you are interested in: 
 

  Hobbies: 

  If you are accepted as an Aliran member, which area would you like to be involved in? 
 
 

  I have read Aliran's Basic Principles and accept them. 

  Applicant's signature:                                                      Date: