Residential Application

Please follow the steps below to complete your application. We will get back to you shortly.

@foreach($data as $a)

Subscription Details

Application Type	{{$a['application']}}
Package	City Broadband Residential {{$a['package']}}
Contract Term	{{$a['subscription']}} Months
Preferred Installation Date	{{$a['thedate']}}

Add-On(s)

Home Voice Plan	{{$a['voice']}}

Personal Details

Full Name	{{$a['name']}}
MyKad/Passport	{{$a['nric_passport']}}
Gender	{{ucfirst($a['gender'])}}
Nationality	{{$a['citizenship']}}
Primary Phone Number	{{$a['contact_primary']}}
Secondary Phone Number	{{$a['contact_secondary']}}
Email Address	{{$a['email']}}

Service Installation Address

Unit Number	{{$a['unit']}}
Building	{{$coverage->building_name}}
Street	{{ucwords($a['street'])}}
Postcode	{{$coverage->postcode}}
City	{{$coverage->city}}
State	{{$coverage->state}}

Monthly Recurring Charges @if($a['voice']=='Yes') @endif

Description	Price exclude ST	Total*
City Broadband Residential - {{$a['package']}}	RM{{ $product->retail_price }}	RM{{ $gst }}
Home Voice Plan	RM20	RM21.20
Total Charges		RM{{ $total_monthly }}

*Price subject to 6% Service Tax (if applicable).
@if ($upfront_total != 0)

Upfront Charges @if ($otc_st != 0) @endif @if ($deposit != 0) @endif

Description	Price exclude ST	Total*
One Time Charges	RM{{ $otc }}	RM{{ $otc_st }}
Deposit		RM{{ $deposit}}
Total Charges		RM{{ $upfront_total }}

*Price subject to 6% Service Tax (if applicable).
All upfront charges will need to be paid prior installation. You will receive an email once your application has been processed. @endif

Declaration and Signature

Document & Declaration *

Photocopy of MyKad (front and back) or passport for Non-Malaysian (minimum 12 months validity) and visa (minimum 6 months validity)

I hereby consent to the collection, use, disclosure of my personal information in accordance with the Privacy Policy available on 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). Allo Technology Sdn Bhd reserve the rights to refuse any application at any given time should any of the information is incorrect.

Upload Documents

Acceptable formats: jpg , jpeg , png , pdf

MyKad/Passport (Front) *

MyKad/Passport (Back) *

Visa (Front) * Non-Malaysian

Visa (Back) * Non-Malaysian

Signature * After you save your signature, the submit button will automatic be display.

@endforeach