iFix iOS Network Installment Form

Application Form (Borang Permohonan)
Application Date / Tarikh Permohonan *

Month Day Year
Date
1. Application Details (Maklumat Pemohon)
Full Name / Nama *
Nama seperti di dalam kad pengenalan.
IC Number / No Kad Pengenalan *
Example : 920101101010
Handphone No. / Tel Bimbit *
Example : 0121234567
E mail / Alamat E mel *
Example : ali@gmail.com
Race / Bangsa *
Sex / Jantina *
Marital Status / Perkahwinan *

2. Address Details (Maklumat Tempat Tinggal)
Address / Alamat *

Street Address

Street Address Line 2

City State

Zip Code
Housing Status / Status Kediaman *
Length of Stay / Tempoh Menetap *
Example : 5 Months or 5 years.

3. Employment Details (Maklumat Pekerjaan)
Company Name / Nama Syarikat *
Company Address / Alamat Syarikat *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Office Tel/No. *
Example : 03 12345678 (Office number only)
Years of Service / Tempoh Berkhidmat *
Example : 5 Months or 5 Years
Position / Jawatan *
Salary / Gaji Bulanan *
Example : 1000
Salary Date / Tarikh Gaji *
Example : 30hb

4. Emergency Contact Person (ECP)
First ECP Details
(1) Full Name / Nama *
Nama seperti di dalam kad pengenalan
Relation / Hubungan *

Parents / Ibubapa Spouse / Pasangan (suami @ isteri sahaja) Sibling / Adik Beradik
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Handphone No. / Tel Bimbit *
Example : 012 1234567
Second ECP Details
Full Name/Nama *
Nama seperti di dalam kad pengenalan
Relation / Hubungan *

Parents / Ibubapa Spouse / Pasangan (suami @ isteri sahaja) Sibling / Adik Beradik Relatives / Saudara Son / Anak
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Handphone No. / Tel Bimbit *
Example : 012 1234567

5. Purchase Details (Maklumat Pembelian)
1. Model (Wajib Isi)
Brand / Jenama *
Model *
2. Tempoh pembayaran semula
Instalment Period / Tempoh Ansuran *
3. Maklumat Akaun Pembayaran (Akaun atas nama pemohon)
Bank *
Account Number *
Example : 162116036499
Signature of Applicant/ Tandatangan Pemohon

Clear
Should be Empty:

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