Loyalty Card Register

Membership Application Form

Sales Consultant : Nominated By:

Date: *

Membership No :

New Member

Renewal Member

How would you like your name to appear on your card, would you prefer initials and surname or first name and surname on your card?

Title *

First Name *

Surename

Where would you like me to send your membership package to, is it to your home adress or your business adress?

Home

Office

Phone 1 *

Phone 2

Email *

Date Of Birth *

Hand Over :

Mrs

Membership No :

Phone

Card No :

Date of Birth Sup :

Relationship

Alamat

PAYMENT METHOD

Credit Card

BCA Virtual Account

Permata Virtual Account

Mandiri Virtual Account

Cash (Transcation only at MGM Office or Pay at Hotel)

Jl. RS. Fatmawati Raya No.100F Cilandak Barat, Kota Jakarta Selatan DKI Jakarta 12430

Layanan Pengaduan Konsumen:

PT. Metropolitan Golden Management

+62 21 75818999

info@myhorison.com