Personal Detail:
Name Of Applicant : (As Per NRIC/Passport)*
Installation Address :
City : eg: Kelana Jaya
Post Code :
State :
Country :
Tel.No. :
(where streamyx is to be connected) eg.0378063300*
Fax.No. :
Mobile No. :
eg: 0163383330
Personal Email :
NRIC :
eg: 800715065621 (Please Enclose a copy of NRIC)*
Passport No. :
(for Non-Malaysian Citizen-Please enclose a Copy of Passport)
Gender :
Date of Birth : MM/DD/YYYY
 
Company Detail:
Company Name :
(For Company Registration Only)
Company Registration No :
(For Company Registeration Only)
 
Application Detail:
Package :
Login ID : (Mininum 3 characters, maximum 8 characters)*
Login ID 1
Login ID 2
Login ID 3
Email ID : (Mininum 3 characters, maximum 8 characters(xxx@streamyx.com))*
Email ID 1
Email ID 2
Email ID 3
Order Remarks : eg . self installation
 
Contact Person Detail:
Contact Person :
Contact Person Phone No :  
Contact Person Email :
 
Copyright © 2007 Mobile Wallet Sdn Bhd. All rights reserved.