EQUIPMENT RENTAL ORDER
HOPKIN ELECTRIC HOSPITAL BED 3 FUNCTION (E32) Deposit: RM 1000, Rental: RM 290/Month/Perbulanan , Delivery/ penghantaran: RM 100 (Delivery Usually On Next Day Payment)
Customer Name / Nama Pelangan:
*
First Name
Middle Name
Last Name
I/C
*
Take Photo Of Your I/C / Sila Ambil Gambar Kad Pengenalan Anda:
*
Phone Number / Nombor Telefon:
*
-
Area Code
Phone Number
Delivery/Pickup Address ( Alamat Penghantaran ):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Date For Delivery / Tarikh Penghantaran:
*
-
Day
-
Month
Year
Date
Preferred Time for Delivery / Masa Penghantaran:
*
Hour Minutes
PM
AM/PM Option
RENTAL MATTRESS ( ONLY FOR RENTAL ):
*
PU MATTRESS - RM 250
RIPPLE MATTRESS (BUBBLE TYPE) - RM 150
NONE
ADD ON / PEMBELIAN ( PWP ) :
*
PU MATTRESS-RM 298.00
RIPPLE MATTRESS (BUBBLE TYPE)-RM 149.00
PRESSURE MATTRESS (TUBE TYPE)-RM 299.00
NONE
Required Additional Charge / CAJ KEPERLUAN PENAMBAHAN:
First Floor installation Fee (RM50)
Second Floor installation Fee (RM80)
Third Floor installation Fee (RM110)
Fourth Floor installation Fee (RM140)
Fifth Floor installation Fee (RM170)
NONE
Total Amount Payable / BAKI PEMBAYARAN:
CONTACT US FOR ASSISTANCE:
+60 18-380 8005 / 03 - 58853936
ONLINE PAYMENT TRANSFER
CIMB BANK - JITRON HEALTHCARE SDN BHD: 8600-66-3982
Proof of Payment / Bukti Pembayaran:
*
Browse Files
Drag and drop files here
Choose a file
Screenshot your payment slip and attach here:
Cancel
of
TERM & CONDITION:
*
Signature (T/tangan)
*
RENT NOW! / SEWA SEKARANG!
Should be Empty: