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Healthie Partner License Void MBG
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2024-12-31T17:30:01+08:00
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PERSONAL INFORMATION
Full Name
(Required)
NRIC No. / Passport No.
(Required)
Contact No.
(Required)
Email
(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
SABAH
SARAWAK
City/Town
(Required)
Please Select
Selected City
(Required)
Postcode
(Required)
Please Select
Selected Postcode
(Required)
Partner | Landlord No.
IMEMBER
Referral Type
iMember
Non-iMember
Name
(Required)
NRIC No.
(Required)
REFERRAL
Registerer Type
(Required)
Landlord/Biz Director/Pre Biz Director/BA
Name
(Required)
Partner Code
(Required)
Customer Referral (Refer 5 Friends Free Ginseng pillow)
Name
(Required)
Phone No.
(Required)
SALES PERSON
Hidden
Verification Type
(Required)
Biz Director
Name
(Required)
No.
(Required)
Selected Payment
DECLARATION
1. I hereby agree to purchase and agreed to pay for the HEALTHIE DIAMOND Products/Rent To Own (RTO) Contract Plan/ Healthie Partner License that I have purchased.
2. I consent that the monthly charges for the above-mentioned product will be charged to the credit card/bank card number indicated on the agreement.
3. I have read, and fully understand and agree to abide by the
terms and conditions
of the HEALTHIE DIAMOND Products Rent To Own (RTO) Contract Plan and Healthie Partner License.
4. I understand that I have the option to personally collect the gifts provided by HEALTHIE DIAMOND or request delivery, and I am willing to bear any additional delivery charges.
5. I have read, understood and agree to the
terms and conditions
of the HEALTHIE DIAMOND Products Rent To Own (RTO) Contract Plan and Healthie Partner License.
BANK ACCOUNT 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
UPLOAD FILE (Void MBG Approval Letter)
Please upload Void MBG Approval Letter
(Required)
Max. file size: 20 MB.
UPLOAD FILE (Form Softcopy)
Please upload Order Form Softcopy
(Required)
Max. file size: 20 MB.
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