STREAMYX HOME
AGENT ID - NAME
APPLICATION FORM
PACKAGE NAME
APPLICATION TYPE
CUSTOMER NAME *
NRIC / PASSPORT NO *
NATIONALITY *
DATE OF BIRTH *
GENDER *
INSTALLATION ADDRESS *
STATE *
CONTACT NO *
ALTERNATE CONTACT NO *
EMAIL ADDRESS *
PREFERRED INSTALLATION DATE *
RUNNER TO COLLECT THUMBPRINT
(NO GUARANTEE)
ORDER NO
EFORM NO
STREAMYX ACCOUNT NO
APPOINTMENT DATE
PORTAL ID
ORDER KEY IN BY
REMARK BY AGENT
REMARK BY ADMIN
IC FRONT *
IC BACK *
UTILITY BILLS (ELECTRIC OR WATER) *
OTHERS (OPTIONAL)
SPECIAL REMARKS (OPTIONAL)
