VSERVICE PLAN BASIC
FULL NAME (AS PER NRIC)
NRIC
BILLING ADDRESS
POSTCODE
CITY
STATE
JOHOR
KUALA LUMPUR
KEDAH
KELANTAN
MELAKA
N. SEMBILAN
PAHANG
PENANG
PERAK
PERLIS
SELANGOR
SABAH
SARAWAK
TERENGGANU
SHIPPING ADDRESS
CONTACT NUMBER
EMAIL
COMPANY NAME
AGENT NAME
AGENT ID
PLEASE CHECK THIS BUTTON
RM120/month x 1 unit
RM120/month x 2 unit
RM105/month x 3 unit
RM105/month x 4 unit
RM105/month x 5 unit
RM90/month x 6 unit
NOTE: If this application form is not submitted together with the required documents will result in your order on hold.
IC PHOTOCOPY (FRONT)
IC PHOTOCOPY (BACK)
Terms & Conditions
I have read, understood and hereby accept all the
Terms & Conditions.
SUBMIT
