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ALLO TECHNOLOGY SDN BHD
Cyberview Garden Villas, Persiaran Multimedia, Cyber 7
63000 Cyberjaya, Selangor Darul Ehsan
Tel: 03-8800 5222 Fax 03-8800 5221
E-mail:customerservice@citybroadband.my
Website:www.citybroadband.my
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BROADBAND INTERNET ACCESS SERVICE APPLICATION FORM
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| Please write in CAPITAL LETTERS and tick(/) where required |
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| APPLICATION: |
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@if($form->Form->type_service == "New")
 }})
@endif
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New |
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@if($form->Form->type_service == "Upgrade")
@endif
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Upgrading/Downgrading |
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@if($form->Form->type_service == "Relocation")
@endif
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Relocation(RM150) |
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@if($form->Form->type_service == "Rectification")
@endif
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Rectification |
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APPLICATION INFORMATION
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| Full Name |
{{ $form->name }} |
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| NRIC/Passport No. |
{{ $form->ic }} |
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| Primary Contact No. |
{{ $form->phone1 }} |
Secondary Contact No. |
{{ $form->phone2 }} |
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| Designation |
{{ $form->designation }} |
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| Citizenship |
- |
E-mail |
{{ $form->email }} |
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INSTALLATION ADDRESS
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| Company Reg.No |
{{ $form->company_reg }} |
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| Company Name |
{{ $form->company_name }} |
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| Unit. No |
{{ $form->unit_no }} |
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| Address |
{{ $form->street }} |
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| City/State |
{{ $form->city }} / {{ $form->state }} |
Postcode |
{{ $form->postcode }} |
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| Company No. |
{{ $form->company_num }} |
Company Fax No. |
{{ $form->company_fax }} |
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SERVICE DETAILS
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| 1. Subscription/Contract Period : |
@if( $package->contract == "12")
@endif
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12 months |
@if( $package->contract == "24")
@endif
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24 months |
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| 2. Required For Service : |
{{ $package->rfs }} |
Billing Cycle |
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| 3. Subscribe for Fixed IP : |
{{ $package->ip }} |
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| 1. Standard contract period is 24 months unless otherwise stated |
| 2. Required For Service (RFS) is subject to the avaiability of required infrastructure and/or equipment |
| 3. Early termination will subject to RM 500 penalty. |
| 4. Separete penalty charge for broadband and voice |
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PACKAGE DETAILS
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| 1. City Broadband Business (Best Effort Bandwith) |
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@foreach($product as $p)
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@if( $package->name == $p->speed )
@endif
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{{ $p->package_name }} |
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@if($p->speed == '10')
RM 149 ( RM {{ number_format(149 * 1.06, 2) }} )
@elseif($p->speed == '30')
RM 259 ( RM {{ number_format(259 * 1.06, 2) }} )
@elseif($p->speed == '50')
RM 279 ( RM {{ number_format(279 * 1.06, 2) }} )
@elseif($p->speed == '100')
RM 299 ( RM {{ number_format(299 * 1.06, 2) }} )
@elseif($p->speed == '300')
RM 999 ( RM {{ number_format(999 * 1.06, 2) }} )
@elseif($p->speed == '500')
RM 1899 ( RM {{ number_format(1899 * 1.06, 2) }} )
@elseif($p->speed == '1')
RM 3499 ( RM {{ number_format(3499 * 1.06, 2) }} )
@endif
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@endforeach
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| *All prices shown in the bracket include 6% Goods and Services Tax (SST) |
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@if($package->voice_fee == "Yes" || $package->voice_fee == "yes")
@else
@endif
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Yes |
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@if($package->voice_fee == "no" || $package->voice_fee == '' || $package->voice_fee == "No")
@else
@endif
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No |
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| Advanced Payment |
| 1 Month Fee : RM {{ $package->montly_fee }} (including GST) |
| Deposit Fee : RM {{ $package->deposit }} |
@if($package->voice_fee == "no" || $package->voice_fee == "No" || $package->voice_fee == "NO")
| Voice Fee : RM 0 |
@elseif($package->voice_fee == "yes" || $package->voice_fee == "Yes" || $package->voice_fee == "YES")
Voice Fee : RM 30 |
@endif
| OTC Fee : RM {{ $package->upfront_payment }} |
| Total : RM {{ number_format(floatval($package->montly_fee) + floatval($package->deposit) + floatval($package->voice_fee) + floatval($package->upfront_payment), 2) }} |
| *Installation fee will be woved for permises with available of required infrastructure |
| **Deposit is refundable |
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DOCUMENTS AND DECLARATION
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| Documents Required: |
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Photocopy of MyKad (front and back) or passport for Non-Malaysian (minimum 12 months validity) |
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| Declarations: |
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| I hereby consent to the collection, use, disclosure of my personal information in accordance with the PRIVACY POLICY available on www.citybroadband.my |
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| I hereby declare that the above information, documents and any appendices attached are true and valid. I have read and undertood the consent of this form and agreed to be bound by TERMS & CONDITIONS as stated on the next page of this form which accompany the subscription of product(s) and/or service(s). Allo Technology Sdn Bhd reserve the rights to refuse any application at any given time should any of the information is incorrect. |
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| By signing this document, I agree and accept TERMS & CONDITIONS stipulated herein. I declare that the information provided by me is true and valid. Allo Technology Sdn Bhd reserve the rights to refuse my application at any given time without any refund or whatever monies held by Allo Technology Sdn Bhd should any of the above informationis found to be incorrect. If the service is offered to me, I declare to be bound by the TERMS & CONDITIONS of the service herein |
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| Submitted Date: {{ $form->created_at }} |
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