SUB DEALER APPLICATION FORM Date :

PERSONAL INFORMATION
FULL NAME:
(as per IC)
Remark (if any): ________________________

NRIC:

DREG MSISDN :

Other Contact: ________________________

**E-Mail:
Company Name:
Business Reg No:
Business Address:

City:
State:

Postcode:

SUB DEALER PACKAGE

1. Subscriber's SIM:

pcs

Total Package Amount: RM

2. Blank SIM:

pcs

Method of Payment:

3. E-Recharge

.00

RM

Payable to: One XOX Sdn Bhd

.00

CASH

CHEQUE :

* kindly retain proof of payment for verification

Maybank: 5622 3667 9813

E-Mail Add: payment@onexox.my

APPOINTED BY (DEALER / DISTRIBUTOR)

Dealer ID:

D Y

Contact No :

Dealer Name:

SUBMITTED BY (DISTRIBUTOR)
Dealer ID:

D Y

Contact No :

Dealer Name:
Payment Detail :
Method :

Cash Deposit Machine

Online Transfer

By Cheque

Cheque No

Reference No :
** Kindly ensure all information and supporting document are completed before submission:
For Office Use :

All Information Completed

Agreement / Contract is Signed

ONE MSISDN Activated

Payment / Proof of Payment

Photocopy of Identification Card (IC)

EL

ONEXOX SDN BHD Lot 5.2 5th Floor Menara Lien Hoe No 8 Persiaran Tropicana Tropicana Golf Country Resort 47410 Petaling Jaya Selangor 03-78825000