E-Warranty Registration Form | Malaysia

1
Full Name* This field is required.As per identity card
2
NRIC/Passport No.* This field is required.
3
Date of Birth* This field is required.
Date
Day
Month
Year
4
Gender* This field is required.
Male
Female
5
Mobile* This field is required.
6
E-mail* This field is required.
7
Address* This field is required.
Address
Street Address
City
State
Postcode
Malaysia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
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Australia
Austria
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Germany
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Greece
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Laos
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Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Please upload your original receipts (s).* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
Please upload your original receipts (s).* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
Purchased from* This field is required.
Medklinn Showroom
Pharmacy Chains
Independent Pharmacy
Electrical Stores
Baby Stores
Organic Stores
Car Accessories Shops
Online Stores
Redemption Programmes
Exhibitions/Roadshows
Others
11
Pharmacy Chains* This field is required.
Caring
Watsons
Ascen Plus
Lesley
Alive
GoodMedic (KL)
Health Link
Srimulia
Unicare
Unipharm
Wellness
AA
12
Electrical Stores* This field is required.
One Living
BHB
Sincere Zone
ESH
Hoe Huat
TBM
13
Baby Stores* This field is required.
Mothercare
Others
14
Organic Stores* This field is required.
BMS Organics
Others
15
Online Stores* This field is required.
Medklinn Online Store
Lazada
Shopee
Vettons
PG Mall
Lelong
Health2U
HomedecShop
Others
16
Independent Pharmacy* This field is required.
17
Car Accessories Shops* This field is required.
18
Others* This field is required.
19
Date of Purchase* This field is required.
Date
Year
Month
Day
20
Number of Unit(s)* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Product Model 1* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
22
Product Model 2* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
23
Product Model 3* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
24
Product Model 4* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
25
Product Model 5* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
26
Product Model 6* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
27
Product Model 7* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
28
Product Model 8* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
29
Product Model 9* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
30
Product Model 10* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
31
Product Model 11* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
32
Product Model 12* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
33
Product Model 13* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
34
Product Model 14* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
35
Product Model 15* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
36
Product Model 16* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
37
Product Model 17* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
38
Product Model 18* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
39
Product Model 19* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
40
Product Model 20* This field is required.
Please Select
Please Select
Autoplus
Autoplus Docking
Asens+20
Asens+40
Asens+60
Versa 25
Versa 45
Versa 45s
PRO X70
PRO X100
PRO AS2
PRO AS3
PRO AS20P
PRO AS30P
PRO AS40P
PRO AS180
Ex: 348-BB-01-12345
41
Warranty Terms & Conditions* This field is required.
42
Privacy Policy* This field is required.
43
Please verify that you are human* This field is required.
44
Email
example@example.com
Should be Empty: