Celcom Biz Registration

Employee Form
Requirements and instructions
Please write in capital letter. Tick or delete where applicable. Photocopy of NRIC/MyKad/Passport for verification and additional supporting documents (if deemed necessary). You must be at least 18 years old to subscribe to this service.

A. Type of Registration
New Registration Mobile Number Plan Contract Period Bundle Devices Promotion OR Monthly airtime rebate Brand/Model Device Price (RM) Amount (RM) Period month month Penalty (RM) Mobile Number Portability (MNP) Prepaid to Postpaid

B. About Yourself
Name ( as in NRIC /MyKad/Passport) Mr. Mdm. Ms. Others e.g. Dr/Dato'/Datin, etc

MyKad Old NRIC/Passport No./ Others Date of Birth Nationality Race Billing Address Postcode Permanent Address Postcode Contact No. (Home/Mobile) Contact No. (Office) Email Address Mother's Maiden Name Company Name Occupation Malaysian
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Non-Malaysian

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Country

C. Reference
Name Relationship Contact No. (Home/Mobile)

D. Monthly Bill Settlement Preferences

Language Bahasa Malaysia English Itemised Bill Yes No

I opt to do auto bill payment via my Credit / Charge Card *Card Type VISA Master Card

( If yes, please complete the following details marked with "*")

AMEX

Diners *Expiry Date

mm yy

* Credit / Charge Card No. *Card Issuer (Bank) *Call Barring (If exceed credit limit) Yes No

E. Mobile Number Portability (MNP)

Donor Network Operator (DNO) Premier Customer Follow DNO Credit Limit Yes Yes Amount (RM) No

F. Value Added Services

International Roaming Celcom Broadband Mobile email solution CLIR SMS Pax Executive Pax Others (please specify)

G. Customer Declaration
By signing this form, you hereby declare that you have read, understood and agreed to be bound by the terms and conditions of the Services as stipulated in www.celcom.com.my/biz. You confirm that the information that you have provided us about yourself is true and accurate and permit us to verify this with any third party. Your application for the Services will be confirmed when we make the Services available to you or upon activation of the Services, as the case may be.

Customer's Signature

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For Office Use Only

H. Details
Account Manager Name Account Manager ID Dealer ID Dealer Stamp

Stamp

Promo Code Segment Code VIP Code

I. DOCUMENTATION CHECKLIST
ITEMS TO CHECK Completed and signed Registration Form Photocopy of NRIC/MyKad Photocopy of Passport / others Special Mobile Number Application Form Perform blacklist checking Mobile No.
Affix SIM Card sticker

Blacklist Release Letter Package Addendum MNP - Other Telco bill Others (please specify) Account No.

SIM card Serial No. CSR CSE 9. 10. 11. 12. 13. 14. 15. 16. Deposit (if any) Advance Payment Value Added Services IDD/ IR installed Penalty Credit Limit Segment Code Device Payment (if any) CSR CSE

ITEMS TO VERIFY 1. Customer's Name 2. MyKad/Passport No. /Others 3. Contact No 4. Address 5. Upfront payment (if any) 6. Mother's Maiden Name 7. Nationality 8. Correct Package Processed By Initial Date of Activation Time Stamp

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Checked & Verified By Initial Date of Activation Time Stamp

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am/pm

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am/pm

Call us at 1-800-111-777 or your dedicated Celcom Biz Account Manager

Celcom Mobile Sdn Bhd ( 27910-A)
Registered office: Level 5, Axiata Centre, 9 Jalan Stesen Sentral 5, Kuala Lumpur Sentral 50470 Kuala Lumpur