• Customer Type*

  • CUSTOMER PARTICULARS

  • Title*
  •  -
  •  -
  •  -

  • Other Customer Particulars (Applicable to Individual only)

  • Date of Birth
     / /
  • Race

  • Gender
  • Rows

  • Additional Service Contact Person Information (Applicable to both Individual and Corporate)

  •  -
  •  -
  •  -

  • Corporate Customer Billing Information

  • Note: Other than Government and bank, E-Invoice feature will be enrolled automatically. Please e-mail to billing@coway.com.my for any change of monthly invoice delivery mode.

  • Rows

  • Order & Payment Information

  • Mattress Package*
  • Mattress Size*
  • Mattress Type*
  • Rows
  • Order Application Type*
  • Outright/Instalment
  • Rental

  • Credit Card / Debit Card Auto Debit Authorisation

  • I hereby authorised Coway (Malaysia) Sdn. Bhd. (Formerly known as Woongjin Coway (Malaysia) Sdn. Bhd.)(“Coway”) to charge my debit / credit card for the amount: Rental Processing Fee (“RPF”) - (One-time deduction upon signing of this Agreement) and Monthly Rental Fee - (Monthly deduction until termination or expiry of this Agreement)

  • Third-Party Payee Payment Authorisation (if any)

  • I/We (Third Party Name - NRIC/Co. No.) agree to be responsible as third-party payee for this order payment by charging my credit card / debit card / savings account.

  • Credit Card/Debit Card/Direct Debit
  • Preferred Installation Date
     / /

  • THIS CONTRACT IS SUBJECT TO A COOLING-OFF PERIOD OF TEN WORKING DAYS

    (Installation will only be done after the cooling-off period unless customer agrees to waive this clause)

  • I/We confirm that the particulars stated above are accurate and true and also acknowledge that I/We have read the Terms and Conditions as set out in the reverse side of this document and hereby agree to the Terms and Conditions set out therein.

  • Internal Use

  • Should be Empty: