Authorized Dealer Application Form
DEALER LOGIN INFORMATION ::
AD Card No :
 
A) DEALER'S PARTICULAR
B) BONUS PAYMENT METHOD
Name :
IC No (New) :
IC No (Old) :
   
Email Address :
   
Company Name :
Company Reg.No. :
Please tick one of the below Bonus Payment Methods.
Direct Credit - Maybank Account
  Auto credit into your Bank account - Bonus will be deposited within 3 working days from the 15th of every month.
E-wallet
Cheque & thru NORMAL POST
  (AD will be responsible to inform Company if Cheques have not been received within 2 weeks after 15th of the month)
   
 
Correspondence Address :
 
Postcode :
Town / City :
Country :
   
Tel No. (Office) :
Tel No. (H/P) :
Fax No :
Tel No. (Home) :
   
Nationality :
DOB : - -
Gender :
Language :
Marital Status :
Race :
 
Beneficiary Information
Name
IC No (New)
Tel No. (Office)
Tel No. (H/P)
   
Spouse's Information
Name
IC No (New)
Tel No. (Office)
Tel No. (H/P)
If you select payment thru cheque, whose name would you like to appear on the cheque?
Payee Name :
Payee IC No :
   
*Note : If you select DIRECT CREDIT PAYMENT METHOD ONLY, please furnish Section C.
C) MAYBANK ACCOUNT INFORMATION
BANK ACCOUNT No :
BANK ACCOUNT Name :
IC No (New) :
IC No (Old) :
C) DIRECT SPONSOR INFORMATION
Code :
Name :
E) PLACEMENT INFORMATION

Code :
Name :
   
 
DECLARATION
I/We hereby confirm that all the information given is true and accurate.