DEALER APPLICATION FORM

A. APPLICATION INFORMATION

Dealer ID
Name (as in NRIC/Passport)

NRIC/Passport
DREG MSISDN - Contact No -
Email Address
Mailing Adress

City
State Postcode

B. COMPANY / ORGANIZATION INFORMATION

Company Name
Business Reg No GST No
Business Type Sole Proprietor Partnership Sdn Bhd Public Listed
Business Address

City
State Postcode

C. DEALER PACKAGE (IJARAH)

Package Amount RM478

1 Starter Pack pcs
2 Blank Sim pcs

D. APPOINTED BY COMPANY THROUGH DEALER / DISTRIBUTOR

Dealer ID Contact No -
Dealer Name

E. SUBMITTED BY

Dealer ID Contact No -
Dealer Name

F. APPLICATION DECLARATION

I hereby declare that the above information given is true, accurate and complete. I have read, understood, agreed and
authorized to be bound by the Terms & Conditions as enclosed. I also agree to be severally liable for all fees and charges
owing. By signing, I would want to cofirm my application to be ONEXOX's Dealer complied by 'Akad Wakalah' to carry
ONEXOX brand. I authorize and consent to One XOX Sdn Bhd to verify the information given herein from whatever
sources as may be required and to release such information as may be obtained without further reference to me. I agree
to provide additional information/documentation when requested by One XOX Sdn. Bhd. from time to time.
Consent
a)I/We consent to One XOX and its related corporations (collectively "XOX"), its agents, business partner and marketing
partners, as well as authorized service providers collecting, using, disclosing and/or processing my/our personal data, in ___________________________________________
order to contact me/us about your and/or their products which One XOX may have in its records from time to time. Applicant Signature & Company Stamp
b)I/We confirm and agree that my/our consents granted herein do not supersede or replace any other consents which
I/We may have previously provided to One XOX in respect of my personal data, and are additional to any rights which
One XOX may have at law to collect, use or disclose my/our personal data.
Date / /

G. FOR ONEXOX/XOX OFFICE USE ONLY

Remark Checked By

Approved Rejected Date / /