iFix iOS Network Installment Form

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

MonthDayYear
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

CityState

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

CityState / 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 / IbubapaSpouse / Pasangan (suami @ isteri sahaja)Sibling / Adik Beradik
Address*

Street Address

Street Address Line 2

CityState / 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 / IbubapaSpouse / Pasangan (suami @ isteri sahaja)Sibling / Adik BeradikRelatives / SaudaraSon / Anak
Address*

Street Address

Street Address Line 2

CityState / 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: