CORPORATE INDIVIDUAL / SME INDIVIDUAL REGISTRATION FORM

Please write in CAPITAL letters and tick () where applicable Case No.

A. CUSTOMER DETAILS
Salutation Full Name (As in NRIC / Passport) NRIC / Passport Number Old NRIC (Applicable for Port-in) Email (Mandatory) Billing Address Postcode City State Contact No. (Office / Home) Contact No. (Mobile) Mr Mrs Ms Others: Nationality Malaysian Non-Malaysian

B. USER DETAILS AND TYPE OF SERVICE PREFERRED

Principal Supp 1 Supp 2 Supp 3 Supp 4

1 Mobile Number 2 Rate plan 3 Type of Service

(New/Pre to Post/Conversion/Renewal/Port in)

4 Talktime Plus or Device Option 5 Mobile Voice Contract Term

(Months)

6 Data Package
(Months)

(Data 250MB/ 500MB / 1.5GB /3GB)*

7 Mobile Data Contract Term 8 BlackBerry Package* 9 BlackBerry Contract Term

(Months)

10 Extra Talk (Extra Biz Hours) 11 Extra Bytes

(Additional Data 250MB /500MB / 1.5GB / 3GB)*

12 Itemised Billing 13 International Direct Dial (IDD) Access 14 International Roaming** 15 Credit Limit 16 Others 17 Others Payment (RM) 1 Device Top up Payment (RM) 2 Advance Payment (RM) 3 Deposit Payment (RM) 4 Roaming Payment (RM) 5 Other Payment (RM) Total Payment
I agree to terminate my existing contract for the respective line(s) registered above (if any) and be liable for early contract termination charges which are applicable.
* ** **
(Only applicable for existing customers who wish to maintain their current credit limit)

Please indicate service type - 2G/3G A standard deposit of RM300 per line will be charged to customers who fail to meet Maxis' criteria for international roaming services. International roaming call charges apply for all calls received while roaming and subject to respective Roaming Operator(s) charges.

C. VERIFICATION AND REDEMPTION OF DEVICE DETAILS

Customer served by (Maxis / Dealer) Registration completed with supporting documents Approved by (Maxis / Dealer) Registration verified and approved by: Device issued by: Kindly attach itemised DO

Name: Date: Remarks:

Name: Date: Remarks:

Name: Date: Remarks:

FOR OFFICE USE ONLY

Dealer / Retail Source Code Parent Account ID Master Account ID Account Category

Promotion / Event Name Account Manager Name Company Name Market Code Collection Code
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D. DIRECT DEBIT DETAILS

This section is for new customers applying for the Direct Debit service and for existing Maxis customers who wish to maintain their Direct Debit service upon conversion. Type of credit card Name as in credit card Credit card number Expiry Date (mm/yy) / / MasterCard VISA AMEX Diners Club

Applicants using a third party credit card must submit an original authorisation letter by the card holder, a photocopy of the physical card and the latest credit card statement. Kindly ensure that the above signature matches the signature on the credit or charge card.

E. SIM CARD AND DEVICE DELIVERY DETAILS

Office Address

Contact Number

Alternate Contact Number:

F. TRANSFER OF OWNERSHIP
I hereby agree to transfer my mobile number(s): ___________________________________ ___ ____________with Maxis / Celcom / DiGi / U Mobile to the applicant's signatory below Important: Must attach a photocopy of Transferer's NRIC (Front and Back) on the same page. Transferers Name

Transferers NRIC / Passport Number

Transferers Signature and Date

G. DECLARATION
By signing below, I / We hereby declare date that (a) I / We wish to subscribe for the aforesaid Services provided by MMSSB in accordance with the applicable Service rate plans; (b) the above information provided is true and complete; (c) I / We have read and agree to the Terms and Conditions set out herein, the General Terms and the Service Terms and Conditions for the Services subscribed herein made available on the website http://www.maxis.com.my/personal/general/tnc_main.asp including the Addendums, rate plans as applicable and any amendments as may be made thereto.

Applicant's Signature and Date

For Applicants who are unable to furnish Company ID tag (Co.s HR Manager / Authorised Signatory to complete the following) I / We acknowledge that the above-mentioned customer is employed by our organisation / company / by a registered contractor of organisation / company (to be completed if the Applicant is unable to furnish Company ID)

HR Manager / Authorised Signature: Name :

Company Stamp

Designation : Date :

Maxis Mobile Services Sdn. Bhd. (73315-V), Level 13, Menara Maxis, Kuala Lumpur City Centre, 50088 Kuala Lumpur.
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