UniFi APPLICATION FORM

SECTION 1 : SERVICES DETAILS* Type of Application : Package : Preferred Service ID :

RESIDENTIAL

Shall be used for Internet, TM WiFi, and other services. Details will be emailed to customer once the package is activated

Option 1 : Option 2 : Option 3 : Preferred Installation Slot :

The earliest 5 days after form submission. Subjected to slot availability

Date :

Time :

SECTION 2 : EXISTING STREAMYX / TM HOMELINE DETAILS

Mandatory for existing Streamyx / TM Homeline Customer

Streamyx Login ID : Please indicate your choice : SECTION 3 : APPLICANT DETAILS Full Name (as per NRIC) : NRIC : Property Type : Installation Address : Postcode : Mobile No. : Email. : SECTION 4 : BILLING INFORMATIONS E Mail (FREE) Itemised Billing (RM8/month) Billing Address (If different from above) : Postcode : City : City : Home Tel. No. :

TM Homeline No. :

Passport No. :

State :

State :

SECTION 5 : APPLICANT AKNOWLEDGEMENT

I, _______________________________________ (UNiFi applicant name), NRIC No. ________________________ hereby accept any and all responsibility for the UniFi service and agree to be liable for any demand/claim and any cost arising from legal action pertaining to my usage of the UniFi service. I understand and agree to accept and bound by the Terms and Conditions which accompany the UniFi service. These Terms and Conditions may be subject to change by Telekom Malaysia Berhad, and I will be notified in a manner as Telekom Malaysia deems appropriate. I confirm that the information given is herein is true and correct. RM10 ___________________________ Customer's Signature Date : ___________________ (dd/mm/yyyy) Stamp Duty

Upon receive this application, Telekom Malaysia Berhad reserves the right to verify any information provided by you and reserve the right to decline any application without any reason thereof and is not obligated to respond to any request on any unsuccessful application. Kindly attach a certified true copy of NRIC or passport.
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