• Customer Type*

  • CUSTOMER PARTICULARS

  • Title*
  • 0/70

  • 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

  • Combo
  • Order Application Type*
  • Service Type*
  • Service Type - Heart Service*
  • Rental Period*

  • Filter Option (Applicable only for Storm II and Lombok III under Heart Service)
  • Outright/Instalment
  • Rental

  • Card Auto Debit Authorisation

  • I hereby authorise Coway (Malaysia) Sdn. Bhd. ("Coway") to charge my debit / credit card for the following sums: Rental Processing Fee (“RPF”) - (One-time charge upon signing of this Agreement) and Monthly Rental Fee - (Monthly deductions until termination or expiry of this Agreement)

  • Third-Party Payee Payment Authorisation

  • I/We (Third Party Name - 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.

  • Credit Card/Debit Card/Direct Debit
  • Old Product Return

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

  • I/We unequivocally and voluntarily wish to waive my/our statutory cooling-off rights; and have the Product Installed immediately upon the expiry of 72 hours hereof.*

  • 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. 

  • * 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

  • Internal Use

  • Date
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