You are on page 1of 1
TAN CHONG EKSPRES AUTO SERVIS SDN BHD (168762.4) New Member / Abli Baru] Renewal / Pembaharuan [1] Tiles Gelaran: Ms. / Cik ] Mrs. / Puan [] Me. / Encik] Full Name as in IC / Passport Biz Reg No / Nama Peruh sepert yang tertra pada Ked Pengenalan/ Passport / Nombor Pendattaran Syarkat UW company registered vile, please state as: egXKX Sah Bh Diver Name Jka sara Kareta Borda sla nytakan sopenth, XXX Sah Bhd ~ Nava Pomandi) INRIC / Passport No, / Biz Reg No / Nombor Ked Pengeralen / Nombor Passport / Nombor Pendattaran Syarikat: Roel Bangsa: Malay / Melayu C] Chinese Gina] Indian # ea] (Others / Lain ain Contact No. / Nemiber Teofon: (H/R) (HP) (or) Correspondence Address / Alamat Surat Menyorat: Postcode / Poskod Email Emel Vehicle Registation No, / Nombor Pendattran Kereta: Mate Suton Mode Nel art Manface Thun Pena CONFIRMATION AND SIGNATURE /PERAKUAN DAN TANDATANGAN ESTEE OO STIVULSICTG By sat ne and accept to iba baScAR Payment Mode / Gara Pembayaran: Cashi Tanai C] Credit Card / Kad eat Bortrastargan a bewah dengan simengshu babs sararmadora: sar sean Offell Reco No, ret Card Gt Ne, Nerbor Rest Ras Kad Ke: berarcan bau Dengen nengorusavanperiotoran in, soy bases den metetia tar der sjrat Ural olen NISCANE yang lrpkan © seblk mk suet phon Sica Rept Dae | Cred Card Ght Oat Trt Rent Ras Kad od Savi Branch Pusat Sais Proceed Dat Tah Dire Signature /Tandatangan b i Spry Dat Tak Ta Kestan Date / Tak, mtr 1019 Kart Brees ra ee eT TERMS AND CONDITIONS f Eotnjscans eon thn tac areata AS.NISCARE @ lapel PRIVATE epoared obvi ence metres exretea

You might also like