Orange Member License Order Form

Selected Products

Validation

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Products

PERSONAL INFORMATION

Full Name(Required)

NRIC No. / Passport No.(Required)

Contact No.(Required)

Email(Required)

Address 1(Required)

Address 2(Required)

State(Required)

City/Town(Required)

Selected City(Required)

Postcode(Required)

Selected Postcode(Required)

Partner | Orange Member No.

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IMEMBER

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Referral Type

iMember

Non-iMember

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Name

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NRIC No.

REFFERAL

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Registerer Type(Required)

C Partner / Biz Director

Name(Required)

Code(Required)

REFFERAL (eCash)

Name(Required)

Code(Required)

SALES PERSON

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Verification Type(Required)

Biz Director

Name(Required)

Code(Required)

Selected Payment

DECLARATION

1. I hereby agree to purchase and agreed to pay for the BIG PLAN and Products 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 BIG PLAN and Products.
4. I understand that I have the option to personally collect the gifts 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 BIG PLAN and Products.

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BANK ACCOUNT INFORMATION

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Account Holder Name(Required)

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Beneficiary Bank(Required)

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Bank Account No.(Required)

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Account Type(Required)

Current Account

Saving Account

UPLOAD FILE

Please upload Order Form Softcopy(Required)

Max. file size: 10 MB.