Joining W124 MBCI

Please fill this form to joining W124 Mercedes-Benz Boxer Club Indonesia.


How do you know about W124 MBCI


 Website (http://www.w124mbci.com)
 SOTR / W124 MBCI events
Mailing list / Direct Email from W124 MBCI
 Others: (please specify below)


First Name

Midle Name

Last Name

Alias Name


Home Address

Phone

PIN BB

Email


Work Address

Job Title

Phone

Cellular

Email


Gender

Male   Female

Civil Status

Single   Married

Religion

Date of Birth

DD MM YYYY

Place of Birth

Citizenship


If you have a spouse, please specify his/her full name

Spouse Name

Childrens Name









Vehicle Data (Mercedes-Benz)

Type

Production Year

Color

Licence Number


Example: B 124 MP / BE 13 EK / W 124 MB / etc.

VIN Number

WDB 

Type

Production Year

Color

Licence Number


Example: B 124 MP / BE 13 EK / W 124 MB / etc.

VIN Number

WDB 

Type

Production Year

Color

Licence Number


Example: B 124 MP / BE 13 EK / W 124 MB / etc.

VIN Number

WDB 


Vehicle Data (Non Mercedes-Benz)

Brand / Type

Production Year

Color

Licence Number


Example: B 124 MP / BE 13 EK / W 124 MB / etc.

VIN Number


Brand / Type

Production Year

Color

Licence Number

VIN Number



EDUCATIONAL BACKGROUND: (Please give full details)
A. Schools, University or other formal training

Institution Name

Year

Completed

Yes  No

Institution Name

Year

Completed

Yes  No

Institution Name

Year

Completed

Yes  No

Professional qualifications or specialized training (e.g. Certified Public Accountant, Certified Racer, Part time

 


Membership in professional societies, Political Party, NGO/LSM, other Automotive Club and activities in civic, public, or international affairs.

 


Achievment. (e.g 1st winner of Indonesia Auto Contest 2003, Runner Up of Tour de Java 08 etc)

 


Please describe the reason why you want to join W124 Mercedes-Benz Boxer Club of Indonesia

 



*I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND COMPLETE.

 

 Yes, I agree