Business Application

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

@foreach($data as $a)

Preview

Subscription Details

Type Application	{{$a['application']}}
Residential Package	10Mbps
Contract Term	{{$a['subscription']}} Months
Prefered Appointment Date	{{$a['thedate']}}

Add-On(s)

Subscribe for Voice	{{$a['voice']}}

Company Details

Company Name	{{$a['company_name']}}
Business Reg.No	{{$a['company_register']}}
Company Contact No.	{{$a['company_number']}}
Company Fax No.	{{$a['company_fax']}}

Technical Contact Person

Full Name	{{$a['full_name']}}
MyKad/Passport	{{$a['nric_passport']}}
Designation	{{$a['designation']}}
Primary Phone Number	{{$a['contact_primary']}}
Secondary Phone Number	{{$a['contact_secondary']}}
Email Address	{{$a['email']}}

Service Installation Address

Address	{{$a['caddress']}}
Postcode	{{$a['postcode']}}
City	{{$a['ccity']}}
State	{{$a['cstate']}}

Montly Recurring Fee

Description	Price excl. ST	With ST (6%)
Broadband Fee	149	157.94
Deposit		149
OTC		0.0
Total Charges		306.94

Declaration and Signature

Document & Declaration *

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

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). Allo Haruman Technology Sdn Bhd reserve the rights to refuse any application at any given time should any of the information is incorrect.

@endforeach