EmailMe Form - Unifi VIP Application Form

Type of application *

(Choose for your type of application for Unifi)

Type of package *

(Please choose your preferred package)

(Existing TM user only)

(For existing TM customer, please choice your option/ not applicable for new applicant)

Applicant Name
(Nama pemohon) *

First Last

NRIC NO *

Example: 810101085544

Mobile Number *

### - ### - ####

Example: 01X-XXX-XXXX

Other Phone

Example: 033XXXXXXX

Home Phone

Example: 033XXXXXXX

Installation Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Type of property *

Landed Property

High Rise (Above 5 Storey)

Email *

NRIC Front Page

NRIC Rear Page

Preffered Service ID

Minimum 5 to maximum 20 characters

Preffered contact method *

Preffered Billing Method
(Bil bulanan) *

RM8per/month will be charge separately of itemised billing method

Billing address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please indicate your billing address if you choose for itemised billing

Preffered Installation Time/Date

Installation date and time is subject to slot availability. The earliest date is 5 days after form submission
(Example: 16/06/2012 5pm)

Important Notes
(Notis Penting)

1. This service is subject to a 24-month contract and termination fee of RM 500 is chargeable for termination of service within the contract period.
2. Please prepared a 4-socket extension upon installation.
3. Minimal drilling is required for landed property installation and 1st 15meter cable is free. Any installation exceed 15meter cable will be charge.
4. A penalty of RM200 shall be charged for premise inaccessibility and/or deferment of installation on the day of installation. Changes should be made 24hours before the appointment date.

Agent / Reseller / Introducer

(For Office Use Only)

Important Notes (Notis Penting)

Important Notes
(Notis Penting)