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Brand Ambassador Application Form
kf_lee
2024-03-01T12:42:51+08:00
Hidden
Partner Type
(Required)
DIAMOND BOSS
DIAMOND MEMBER
PERSONAL INFORMATION
Full Name
(Required)
NRIC No.
(Required)
Contact No.
(Required)
Email Address
(Required)
Address 1
(Required)
Address 2
(Required)
State
(Required)
Please Select
JOHOR
KEDAH
KELANTAN
KUALA LUMPUR
MELAKA
NEGERI SEMBILAN
PAHANG
PENANG
PERAK
PERLIS
PUTRAJAYA
SELANGOR
TERENGGANU
City/Town
(Required)
Please Select
Selected City
(Required)
Postcode
(Required)
Please Select
Selected Postcode
(Required)
Partner Code
Hidden
SIGN UP BY
Hidden
BD/Partner Name
(Required)
Hidden
BD/Partner Code
(Required)
Hidden
CATEGORY
Hidden
Customer Type
(Required)
Direct Customer
iMember Customer
Hidden
REFERRAL BY
Hidden
iMember/SP Partner Name
(Required)
Hidden
iMember/SP Partner Code
(Required)
VERIFIED BY BIZ DIRECTOR
Biz Director Name
(Required)
Biz Director Code
(Required)
DECLARATION
TC
(Required)
I hereby request to apply for the above payment mode for my HEALTHIE DIAMOND BRAND AMBASSADOR LICENSE and authorised the Company to deduct my credit card / debit card as per stated below (if initial payment via credit card / debit card).
I have read and fully understand and agree to be abided by the
terms and conditions
of the HEALTHIE DIAMOND BRAND AMBASSADOR LICENSE.
Signature
COMMISSION CREDITING BANK INFORMATION
Account Holder Name
(Required)
Beneficiary Bank
(Required)
Please Select
AFFIN BANK
ALLIANCE BANK
AL RAJHI BANK
AMBANK
BANK RAKYAT
BANK MUAMALAT MALAYSIA BERHAD
BANK SIMPANAN NASIONAL
BANK ISLAM MALAYSIA
CIMB
CITIBANK
Hong Leong Bank
HSBC BANK MALAYSIA BHD
Maybank Berhad
OCBC BANK
Public Bank Berhad
RHB Bank
STANDARD CHARTED BANK
UOB BANK
Bank Account No.
(Required)
Account Type
(Required)
Current Account
Saving Account
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