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House Type: Rumah SELANGORKU Type C, 850 sq ft Chosen Area: Daerah Petaling,
Mukim Bandar Petaling Jaya Selatan
Your name: Old I/C No. / Police No. / Military No.
New I/C No.* Date of Birth*
Citizenship* Identity No. (if non-citizen)
Age* State of Birth*
Race Other Races (please state)
Bumiputra
(if other races) Gender*
Marital Status* Disablement*
Disability Statement
(if yes) Residential/Mailing address*
City Postcode*
State* District (if Selangor)*
Home Phone No. Mobile Phone No.
Email Duration of Resident In Selangor *
Residential Type*