Sales Order No.

DATE NE ID : _______________
CUSTOMER PARTICULAR
NAME AS PER I/C : ____________________________________________________________________
I/C NUMBER : ___________________________________________
BILLING ADDRESS : ____________________________________________________________________
___________________________________________ POSTCODE: ________________
INSTALLATION ADDRESS : ____________________________________________________________________
___________________________________________ POSTCODE: ________________
CONTACT INFO : __________________ (H/P) __________________ (H) __________________ (O)
EMAIL ADDRESS : __________________________________________

SEX : MALE □ FEMALE □

CUSTOMER EMERGENCY CONTACT PERSON
NAME AS PER I/C : ____________________________________________________________________
CONTACT INFO : __________________ (H/P)
RELATIONSHIP : __________________

PRODUCT MODEL & PAYMENT INFORMATION

PRODUCT QTY RM PRODUCT QTY RM PRODUCT QTY RM
WATER PURIFIER FUSION STAND □ BLENDER
MARVEL □ DELUXE □ MAX BLENDER □
KING TOP □ JAZZ □ REMARK
IRIS TOP □ AIR PURIFIER
FUSION TOP □ B-MODEL □
ICON □ C-MODEL □
OUTRIGHT NORMAL PLAN 18 30 48 72
RENTAL GOOOD PLAN 24 36 60 84
DEBIT/ CREDIT CARD/ ACC. NO. :
ISSUED BY : _______________ EXP DATE: _____MM/_____YY
NAME ON CARD : _____________________________________________
PAYMENT INFO
DIRECT DEBIT □ EPP REMARK
CASH □ 6 □ 24 □
CHEQUE □ 12 □ 36 □
PREFERRED INSTALLATION DATE : / / (DD/MM/YY)
SIGNATURE

CUSTOMER NAME : DATE :

I/C NO. :
FOR INTERNAL USE
REMARKS :
ORDER NO. :
RESELLER/ NATURAL EXECUTIVE NAME :
RESELLER/ NATURAL EXECUTIVE CODE :