Business Application 100Mbps

Address *

City *

State *

Postcode / Zip Code *

Type Application *

New Upgrade Relocation (Rm 150)

Company Name *

Business Registration Number *

Company Contact No. *

Company Fax No.

Full Name *

NRIC / Passport *

Designation *

Primary Contact No. *

Secondary Contact No.

Email *

Front IC / Passport *

Rear IC/ Passport *

Company Form A / Form B *

Company Form D *

You have selected:

Business package - 100Mbps

Subscription / Contract Period *

12 Months 24 Months

Billing Cycle *

Monthly

Would you like to subscribe for Voice ( Rm 30) ?

Required For Service (RFS), Date *

Notes:

1. Standard contract period is 24 months unless otherwise stated.

2. Required For Service (RFS) date is subject to the availability of required infrastructure and/ or equipment.

3. Early termination will subject to RM500 penalty.

Declaration and Signature

Document & Declaration *

Photocopy of NRIC (both sides) or passport (Non-Malaysian)

Photocopy of Form 9, 24, 44 & 49

I hereby consent to the collection, use, disclosure of my personal information in accordance with the Privacy Policy available one www.citybroadband.my.

I hereby declare that the above information, documents, and any appendices attached are true and valid. I have read and understood the contents of this form and agreed to be bound by Terms & Condition as stated on the next page of this form which accompany the subscription of product(s) and/ or service(s). Setia Haruman Technology Sdn Bhd reserve the rights to refuse any application at any given time should any of the information is incorrect.