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BORANG PENDAFTARAN
USER REGISTRATION FORM

(Please fill all fields marked with *)

Maklumat peribadi / Personal details
Nama Penuh / Full Name *
Title Mr.  Mrs.  Miss  Mdm.  Dr.  etc
No. K/P (I/C No.) 600101-07-5500
Tarikh Lahir / Date of Birth *
Alamat / Address *
 
Poskod / Post Code *
Alamat E-mail
No. Kontact pertama/ 1st. Contact No. * (can key in phone no or h/p no.)
No. Kontact kedua/ 2nd. Contact No.

Sila tanda yang berkenaan / Please tick each of the boxes which apply to you:
Saya menguna kerusi roda / I am a wheelchair user
Saya mempunyai kecacatan akal / I have an intellectual disability
Saya ada kecacatan penglihatan / I am partially sighted or blind
Saya ada kecacatan bercakap/pendengaran / I have a speech/hearing impairment
If you have another disability that we should know about please give details here:
Jika anda menguna kerusi roda, bolehkah anda menalihkan diri ke kerusi biasa?
If you use a wheelchair can you transfer to a bus seat? 		Ya / Yes   Tidak / No

Kekerapan anda ingin menggunakan perkhidmatan pengangkutan Mobilti?
How often do you expect to use the service?
(eg. Tiap-tiap hari, sekali seminggu, sekali sebulan)
Kemana anda hendak pergi dengan perkhidmatan Mobiliti? (Anda boleh nyatakan lebih dari satu tempat)
Where would you like the transport service to take you ? (You can specify more than one place)
(eg. University Hospital/Mid-valley Mega Mall/ Day-Care Centre/Work)?
Sila nyatakan maklumat lebih lanjut untuk memastikan keselamatan dan keselesaan semasa menguna perkhidmatan Mobilti.
Is there anything else we need to know to ensure you are transported safely and comfortably?

Jika ada kecemasan, pihak Mobilti boleh menghubungi siapa?
Please give details of someone we can contact on your behalf in an emergency.
Nama / Name *
Berhubungan / Relationship (e.g. anak / son) *
Alamat / Address *
 
No. Kontact pertama / 1st. Contact No. * (can key in phone no or h/p no.)
No. Kontact kedua / 2nd. Contact No.
   
   

Verify Code:

 7960


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