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Application Form
Application Form
Personal Particulars
Name in Full: Dr/Mr/Mrs/Mdm/Ms
TITLE: PBM/BBM/BBM(L)/JP
Please attach passport size photo
NRIC Number
Race
I consent to allow The Grassroots’ Club to share my personal details with PA or any other organization to verify my Grassroots Leader status.
Date of Birth
Country of Birth
Marital Status
Gender
Male
Female
Address
Postal Code
Contact Nos.
Email Address
Constituency
Committee(s)
Position
Position
From
To
Membership Fees
Membership Type
Principle Membership
Principle Membership with Family Membership
Youth Membership (15 - 35 Years old)
Youth Membership with Family
Senior Membership (65 years old and above)
Senior Membership (65 years old and above) with Family
PA Staff
PA Staff with Family Membership
Number of Years
*Kindly Tick the appropriate Membership Years.
Principle Membership
1 Year - $120
2 Year - $200
3 Year - $240
5 Year - $300
Principle Membership
With Family Membership
1 Year - $160
2 Year - $260
3 Year - $330
5 Year - $450
Youth (15 to 35 Years old)/Senior (65 Years old & above) Membership
1 Year - $60
Youth (15 to 35 Years old)/Senior (65 Years old & above) Membership
With Family Membership
1 Year - $100
PA Staff
1 Year - $60
PA Staff
With Family Membership
1 Year - $100
*Family Membership Fees applicable to 1 family unit for immediate family members. Documents to submit: A photocopy of the Marriage Certificate and / or Children(s) Birth Certificate (if applicable) + Log card if the car is registered under your spouse’s name.
Spouse's Particulars
Name in Full:
Please attach passport size photo
Please attach photocopy of the Marriage Certificate
NRIC Number
Date of Birth
Occupation
Contact Number
Children Particular
Name in Full:
Please attach passport Size Photo
Birth Certification Number
Date of Birth
Gender
Male
Female
Name in Full:
Please attach passport Size Photo
Birth Certification Number
Date of Birth
Gender
Male
Female
Name in Full:
Please attach passport Size Photo
Birth Certification Number
Date of Birth
Gender
Male
Female
Name in Full:
Please attach passport Size Photo
Birth Certification Number
Date of Birth
Gender
Male
Female
Vehicle No.
Car Plate Number
IU Number
Please Upload Log card
Spouse Vehicle No.
*Only Applicable if spouse has family membership
Car Plate Number
IU Number
Please Upload Log card
By Checking the following checkbox, you agreed to the following Terms and Conditions below
I, hereby confirm that the above information is true and complete
I consent to allow The Grassroots’ Club to send marketing information about their goods or services including notifying me of their marketing events, initiatives and promotions, lucky draws, membership, rewards schemes and other promotions.
I, agree to comply with and be bound by the Constitution, Bye-laws and Rules & Regulations of the Club.
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