Service Application Form (SA)

Service Application No.
SA No.
SA*
SA No.
Service Application No. (T&C)*
SA No.
Customer's Particular
Full Name as per IC or Company Name *
Installation Address (Malaysia Only)*

Address ( Max 70 letters including space)0/70
Address 2 ( Max 35 letters including space)
Address*

Street Address

Street Address Line 2 & City

CityState / Province

Postal / Zip Code
Postcode*
5 digits only
State*
NRIC (New)/Passport/Company No.*
Exp: 85111808XXXX
Tel (Mobile) (1)*
Exp: 0122215XXX, without hyphen '-'
Tel (Residence)(1)
Exp: 0122215XXX, without hyphen '-'
Tel (Office) (1)
Exp: 0122215XXX, without hyphen '-'
Ext.
E mail (1)
example@example.com
Additional Service Contact Person Information

(Applicable to both Individuals and Corporates)
Contacts same as above?

YESNO
Second Contact Person
Tel (Mobile) (2)
Exp: 0122215XXX, without hyphen '-'
Tel (Residence)(2)
Exp: 0122215XXX, without hyphen '-'
Service Address (Malaysia Only)

Address ( Max 70 letters including space)0/70
Address 2 ( Max 35 letters including space)
Postcode
5 digits only
State
Product & Payment Information
How many service order purchase?*

1234
1. Order No*
1. Model*
1. Outright Service Package*

1 year2 years
1. Amount (Package Price)*
1. Amount (Expired Filters)
1. Promotion Code
2. Order No
2. Model
2. Outright Service Package

1 year2 years
2. Amount (Package Price)
2. Amount (Expired Filters)
2. Promotion Code
3. Order No
3. Model
3. Outright Service Package

1 year2 years
3. Amount (Package Price)
3. Amount (Expired Filters)
3. Promotion Code
4. Order No
4. Model
4. Outright Service Package

1 year2 years
4. Amount (Package Price)
4. Amount (Expired Filters)
4. Promotion Code
Grand Total (RM)*
Service Package Payment Information
Outright Payment Type

CashChequeCredit / Debit CardOnline
Instalment Payment Period

6M12M18M24M36M
Credit Card / Debit Card Auto Debit Authorisation

I/We hereby authorise Coway (Malaysia) Sdn. Bhd. ("Coway") to change [RM] per transaction to my/our debit/credit card immediately.
[RM]
Card No.
Card No. (Last 4 digits)
Card Holder Name
Issuing Bank
Expiry Month (MM)
Expiry Year (YY)
Signature & Stamp

Clear
3rd Party Payee Payment

Yes
Third-Party Payee Payment Authorisation

I/We [Full Name as per NRIC], [NRIC/Co. No] hereby authorise payments for this Order to be charged to/deducted from my credit card/debit card/savings account, as a third party payee.
[Full Name as per NRIC]
[NRIC/ Co. No.]
Exp: 85111805XXXX
Credit /Debit Card/ Bank Statement

A copy of NRIC/SSM and Credit/Debit Card/Bank Statement submitted.
Card No.
Card No. (Last 4 digits)
Issuing Bank
Expiry Month (MM)
Expiry Month (YY)
Signature & Stamp

Clear
THIS CONTRACT IS SUBJECT TO A TEN WORKING DAYS COOLING-OFF PERIOD
I/We unequivocally and voluntarily wish to waive my/our statutory cooling-off rights; and have the Services initiated immediately upon the expiry of 72 hours hereof.*

AgreeDisagree
I/We declare that:
(I) the particulars stated above are true and correct;

(II) I/we have read and agree to be bound by the Terms and Conditions set out herein and on the reverse side of this Form;

(III) I/we the undersigned hereby give my/our consent to CTOS Data System Sdn Bhd, Coway’s appointed credit reporting agency to disclose my/our credit information to Coway for the purposes of determining my/our credit standing;

(IV) I/we have read Coway’s Privacy Notice at https://www.coway.com.my/privacy-notice and consent to the collection and processing of my/our personal information by Coway in accordance with Coway’s Privacy Notice;

(V) I/we have obtained the prior consent of the Second Contact Person stated above for the collection and processing of his/her personal information by Coway in accordance with Coway’s Privacy Notice.
*I/we agree to receive marketing and promotional information about products/services offered by Coway and/or which Coway believes may be of interest to me/us (“Marketing Messages”) by any modes of communication
*You have the right to opt out of receiving Marketing Messages by ( clicking on the " link provided in each email/SMS you might receive or ( by contacting our Toll Free Careline at 1800 888 111.
Customer Signature /Date

Clear
Customer Signature /Date (T&C Page)

Clear
Coway Sales Person Use Only
Name
Code
TR No.
Mobile No
Exp: 012221XXXX, without hyphen''-''
Service Package Quotation No
Service Package No
Should be Empty:

Additional Service Contact Person Information

Product & Payment Information

Service Package Payment Information

Coway Sales Person Use Only