1. No category

SUB DEALER APPLICATION FORM
Date :
PERSONAL INFORMATION
FULL NAME:
(as per IC)
Remark (if any): ________________________
NRIC:
-
DREG MSISDN :
Other Contact: ________________________
**E-Mail:
Company Name:
Business Reg No:
Business Address:
City:
State:
Postcode:
SUB DEALER PACKAGE
1. Subscriber's SIM:
pcs
Total Package Amount: RM
2. Blank SIM:
pcs
Method of Payment:
.00
RM
3. E-Load:
Payable to: DYCOM SDN.BHD.
.00
CASH
CHEQUE :
* kindly retain proof of payment for verification
Maybank: 5123 4362 8932
E-Mail Add: [email protected]
APPOINTED BY (DEALER / DISTRIBUTOR)
Dealer ID:
D Y
Contact No :
-
Dealer Name:
SUBMITTED BY (DISTRIBUTOR)
Dealer ID:
D Y
Contact No :
-
Dealer Name:
Payment Detail :
Method :
Cash Deposit Machine
Online Transfer
By Cheque
Cheque No
Reference No :
** Kindly ensure all information and supporting document are completed before submission:
For Office Use :
All Information Completed
Agreement / Contract is Signed
ONE MSISDN Activated
Payment / Proof of Payment
Photocopy of Identification Card (IC)
EL
Onexox Sdn Bhd (1072 886-D) 29-3 Block B, 72A Jaya One, Jalan Universiti ,46200 Petaling Jaya Selangor