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EFAIZENT Network ( LA 0004838 - X )
No. 29. Lorong Bunga Bakawali 4,
Taman Penampang,
Batu 2 1/2. Jalan Penampang,
88200 Kota Kinabalu, Sabah.
Malaysia.
Phone : 088 - 456361
Fax : 088 - 456362
Mobile Phone : 019 - 8813858

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Reseller Application Form

Full Name : *
	( As on your phone bill and NRIC or Passport )
Gender :
NRIC No. :
	( Old IC Number is not Accepted )
Email : *
	( Must be Valid* Email* )
Address :
( As on your Telekom Phone Bill )
City :
Zip / Postcode :
State :
House Phone No. :
	( Where Streamyx is to be installed )
Mobile Phone No. : *
	( For contact purpose )

	Company Detail If Use Company Name
Company Name
Company No :
Address 1 :
Address 2 :
City :
Zip / Postcode :
State :
Office Tel No. :
Office Fax No. :

	Bank Account
Bank Name :
Account Name :
Account No. :
Remarks :

Declaration :
I hereby declare that the above particulars are true and complete and I hereby apply to be an appointed Agent under EFAIZENT Network I also understood accept to the company term and condition for appointed as a Agent. I agree that the companies reserve the absolute right to decline my application without giving any reason. I shall also be the bound by the rule & regulations of the company.