E-numx Stockist Application

e-Sky, Inc. USA : 1584 Meridian Avenue San Jose, CA 95125 USA tel: +1.408.587.7999 Malaysia : 51-01-02, Jalan Austin Heights 3, Taman Mount Austin 8 1100 Johor Bahru, Johor tel: +60.7.352.7777 fax:+60.7.3578177 [email protected] ; www.e-numX.com BORANG PERMOHONAN e-numX Mobile Stockist / Stockist APPLICATION FORM

Nama Name

Tarikh Lahir Date of Birth

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No. KP IC No.

(dd/mm/yy)

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Jantina Sex

Lelaki Male

Taraf Perkahwinan Marital Status

Bujang Single

Perempuan Female Kahwin Married

Alamat Adress Poskod Tel No.

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Rumah / House

Pejabat / Office

Bimbit / Mobile Fax No.

Email

Bank Account No

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MBB

PBB

RHB

Branch BUTIR-BUTIR PENAJA / SPONSOR’S INFORMATION Nama/Name ______________________________________________

BUTIR-BUTIR UPLINE / UPLINE’S INFORMATION Nama/Name _______________________________________________

e-numX Account No.

e-numX Account No.

BUTIR-BUTIR SUAMI/ISTERI / SPOUSE’S INFORMATION Nama Name

No. KP IC No.

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Saya seperti nama di atas mengesahkan bahawa semua kenyataan di atas adalah benar dan betul. Saya telah memahami sepenuhnya segala syarat-syarat dan peraturan-peraturan am yang telah ditetap oleh eSky e-numX dan bersetuju mematuhi segalanya. ____________________________________________________

I, the above named applicant hereby certify that all the above information are true and correct. I have read and understood all eSky e-numX’s Terms and Conditions and Rules and Regulations, and agreed to abide by them.

UNTUK KEGUNAAN PEJABAT / FOR OFFICE USE ONLY

Tandatangan / Signature -

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2

0

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User Name : Password : Received by Checked by All cheque payments to be made to : ESKY MULTIMEDIA SDN BHD (Public Bank Acct. No. 3124173823)

EDP