Home Broadband Application

A. Application Type

Order Type

New Order Relocation Renewal

Plan Tier

Basic Advance Premium Premium +

Referral Code

B. Personal Information

Full Name *

MyKad No

Passport No

Provide either MyKad No or Passport No.

Nationality *

Mobile No *

Emergency Contact *

Email ID *

C. Installation Address

New Address *

Old Address

Postcode *

City *

D. Service Contract

2 years No Contract Complimentary

E. Service Charge Detail

Package *

Basic RM99 /month Advance RM111 /month Premium RM123 /month Premium + RM135 /month

Installation

RM 500 — No Contract No Deposit — 2 years contract

F. Document Checklist

Photocopy of MyKad Photocopy of Passport

G. Applicant Declaration

I hereby declare that all information are true in each aspect, I understand and agree to be bound by Terms and Conditions stated in this form. View Terms & Conditions

Name *

Signature (full name) *

Date *