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 info@eskyglobal.com ; www.e-numX.com

BORANG PERMOHONAN e-numX Mobile Stockist / Stockist APPLICATION FORM

Nama
Name

Tarikh Lahir Jantina Lelaki Perempuan

Date of Birth - - (dd/mm/yy) Sex Male Female

No. KP Taraf Perkahwinan Bujang Kahwin

IC No. - - Marital Status Single Married

Alamat

Adress

Poskod

Tel No.
- -
Rumah / House Pejabat / Office

Bimbit / Mobile

Fax No. Email

Bank Account No . MBB PBB RHB

Branch

BUTIR-BUTIR PENAJA / SPONSOR’S INFORMATION BUTIR-BUTIR UPLINE / UPLINE’S INFORMATION

Nama/Name ______________________________________________ Nama/Name _______________________________________________

e-numX Account No. e-numX Account No.

BUTIR-BUTIR SUAMI/ISTERI / SPOUSE’S INFORMATION

Nama
Name

No. KP
IC No. - -

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 Tandatangan / Signature
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. - - 2 0
-
UNTUK KEGUNAAN PEJABAT / FOR OFFICE USE ONLY

User Name :

Password :

Received by Checked by EDP

All cheque payments to be made to : ESKY MULTIMEDIA SDN BHD (Public Bank Acct. No. 3124173823)