Application Form For Marriage Preparation Course

*Please circle the intended date

18-19 June 2011 (Malay) / 22-23 Oct 2011 (Eng)*

Applicant's Information Partner's Information

Name (as in IC) Name (as in IC)

Gender Gender

Citizenship Citizenship

NRIC/FIN NRIC/FIN

Address Address

Postal Code Postal Code

Handphone No. Handphone No.

House phone No. House phone No.

Email Email
Date of Birth Date of Birth
[DD/MM/YYYY] [DD/MM/YYYY]
Race Race
Academic
Academic Achievment
Achievement

Language Proficiency Language Proficiency

Occupation Occupation

Income Income

Marital Status Marital Status

Islamic Knowledge Islamic Knowledge

Blood Type Blood Type

Mode of Payment

Mode of payment:

j Cash /NETS at Reception/ Cyber Corner (Mon-Friday: 9:00 am to 5:00 pm at Reception Counter)
(Sat: 9:00 am to 1pm or 2-5 pm at Cyber Corner) (Sun: 9:00 am to 2 pm at Cyber Corner)

k Crossed cheque payable to LPM Assyakirin. Please indicate marriage prep course, name and Hp no. at the back of chq.
l Direct Debit/ Internet Bank Transfer to OCBC Current A/C : 622-853976-001. Please email reference no. and date of transfer

Registration
All registrations can be faxed to Assyakirin Mosque at: 6268 9725.
Alternatively, you may email the registration to norhalizah@assyakirin.mosque.org.sg

Course Fee
Course fee is SGD 130 per person, inclusive of educational materials, certificate of completion & refreshments.
Confirmation of registration is subject to FULL PAYMENT of course fee within 14 working days of registration.
After which, registration will placed in the waiting list under first come first served basis.

Participant’s Attendance
Participants are required to meet 100% attendance. Certificate of Achievement will be awarded to participants upon completion of the
course. If absence in any part of the course, the Certificate of Achievement will not be issued.
Assyakirin Mosque reserves the right to update the terms and conditions from time to time as necessary.

Withdrawal and Refund – The following conditions apply:

There will be NO Refund of Fees. Participants who wish to withdraw from the curent intake will be transferred to the next available intake in Assyakirin
Mosque. Should there be no available intake, the full payment will be regarded as donation to the mosque.

Additional Information
Maximum participants per course - 50 people.Course will only commence when there are a minimum of 38 paid participants.
Please ensure that you are AT LEAST 21 years of age at the time of registration.
If you are a divorcee, you should not have children below 12 years of age.
Contact Info
Ms Norhalizah Rosley at Tel:6268 1846 ext 109 / Email: norhalizah@assyakirin.mosque.org.sg