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Salutation*

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Preferred Name*

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Passport Expiry Date

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Contact No.*

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IoD Country*

IoD Membership Certificate*

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Membership Category* Membership Benefits

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1-Year Plan (standard)

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Current/Past Working Experience

Company Name*

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Industry*

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Designation*

Position*

Year Start*

Still current/ Present

Year End*

Board Experience

Board Experience #1

Company Name*

Type*

Industry*

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Board Company Website*

Designation*

I confirm that this private company met the RM3 mil annual revenue requirement.

Year Start*

Still current/ Present

Year End*

Board Role*

Total Board Experience: (Calculation based on provided dates)

0 years

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city*

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Country*

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Consent & Declaration

Consent & Declaration*

I hereby apply for membership of the ICDM and I irrevocably agree to be bound by ICDM By-Laws and all rules and regulations made by ICDM from time to time. I confirm that:

I am not disqualified (by court order or voluntary undertaking) from being a director of any company, nor am I aware of any circumstances which may lead to such disqualification.
I do not have any criminal convictions (other than compounds for traffic offences);
I am not an undischarged bankrupt nor am I aware of any circumstances that may lead to bankruptcy proceedings being brought against me; and

I hereby undertake:

to comply with the Rules of ICDM;
to conduct myself, both publicly and privately, in a professional manner and so as to uphold the ICDM’s reputation as stipulated in ICDM Code of Conduct; and
not to represent publicly the views of the ICDM or to claim its support, without the consent of the Board (or of an officer or employee of the ICDM nominated by the Board for such purpose); and

I hereby consent to ICDM:

To create an account in the ICDM Portal for me & update the provided information accordingly.
The use of my personal information and all information provided by me for the purposes set out under ICDM’s Privacy Policy as revised and updated.
Any changes to our terms of use or Privacy Policy, will be reflected on the website. Continued usage of the service will signify that you agree to any such changes.

I agree to pay the applicable amount along with my membership application.

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