Apply to join the programme.
It will only take a few minutes. At the end there is a
send
button. Press it and your completed form will be emailed to us."
Title:
Mr
Mrs
Ms.
Name:
E - mail:
E-mail (Reconfim your email as email is our primary communication mean):
Address:
Post Code:
Mobile:
Work Tel:
Age:
Marital Status:
Married
Single
No. of children:
Vehicle Make:
Colour:
Model:
Number of Doors (including hatchback):
Year:
How many hours per day do you spend in your car?
What is your average mileage in total per year?
How many of these are on business?
Do you regularly use a Expressway?
Yes:
No:
If Yes which ones:
How many mileage are spent in commuting to and from work/school?
What is the approximate distance from home to work/school?
At home where is your vehicle parked?
On my drive at home
In a public open air car park
In a private covered car park
In my garage
On a busy road
On a quiet road
Is your car visible by others when it is parked overnight?
Yes;
No:
During the day where do you park your vehicle?
In a public open air car park
In a private covered car park
On a busy road
On a moderate road
On a quiet road
When your car is parked at work, how many people can see it?
Not very many
Some
A lot
Not very many
Household Income:
Under $20,000
$20,000 to $40,000
$40,000 to $60,000
$80,000 to $100,000
Over $100,000
Employment Status:
Work Full-Time
Full-Time Student
Work Part-Time
Part-Time Student
Not Employed
Full-Time Homemaker
Occupation:
Sales/Marketing
Executive/Management
Administrative/Clerical
Technical
Teacher/Professor
Skilled Craftsman
Service Worker
Retired
Self-Employed
Full-Time Parent
Student
Other
Industry:
Automotive
Manufacturing
Utility
Medical/Dental
Legal
Internet/e-Commerce
Marketing/Advertising/Public Relations
Financial
Science/Engineering
Food Services/Hospitality
Government
Transportation
Arts/Music/Writer/Film
Technology/Communications
Entrepreneur
Other
Do you regularly shop at a supermarket?
Yes:
No:
If Yes how many times per month:
Approximately how far away is your supermarket from you:
How many times per month do you take your car to shop in Orchard Road?
Never
1-2
3-8
Over 8
Approximately how far away is Orchard Road from you?
How many times per year do you use your car for holidays/weekend breaks:
I don't
0-1
2-4
4-6
7 or more
How many times per year do you visit West Malaysia by your car?
Do you regularly visit a health or sports centre by car?
Yes:
No:
If Yes how often per week:
1-2
3-4
4-7
Over 7
How far is the health or sports centre from you (one way)?
0-3 kilometers
4-6 kilometers
7-10 kilometers
Over 10 kilometers
Using you car, which other recreational activities do you participate in (tick where applicable):
Angling
Golf
Motor Sport
Football
Rugby
Horse Racing
Concert Going
Walking Hiking
Sailing
Surfing/Windsurfing/Body boarding
By submitting your application, you abide to the
terms & conditions
.
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