ARISSTO (MALAYSIA) SDN. BHD.

(677262-T) TERMINATION & DISMANTLING FORM

(Formerly known as NEP DIAMOND Marketing Sdn. Bhd.)
Block B, South City Plaza, Persiaran Serdang Perdana,
计划终止与拆还表格
A R I S S T O I T A L Y Taman Serdang Perdana, Seksyen 1,
43300 Seri Kembangan, Selangor.
Serial No. : PT 0000001
Ref No. MJS / MJS编号:
Tel: +603-8947 3333 Whatsapp: +6012-377 3498

A. Customer Category 客户类别

Contract 合约 Membership No. 会员编号: (Agreement No. 合约编号: )

Outright Purchase 买断式采购 Free Product Experience 免费产品体验 Reply Note Serial No. 回复编号:

B. Product Details 产品详情

1. Product Dismantled and Returned : Yes 是 No 不是 Product Dismantled & Plan Termination Date :
产品拆解并退还 产品拆还及计划终止日期
Product Model 产品型号: Product Serial No. 产品序列号:

2. Please tell us why you wish to terminate？ 请问为什么您要终止计划？

3. Missing Parts (if any) 遗失零件(如有)

No. 编号 Item Description 项目详述 Quantity 数量 Unit Price 单位价格 (RM) Total 共计 (RM)
1.
2.

Grand Total 总额 (RM):

C. Customer Details 客户详情

Full Name as per IC 姓名(如身份证) :
Address 地址 :
Postcode 邮区 :
Tel. No. 电话号码 : - H/P No. 手机号码 : -

D. Declaration 声明

(1) I hereby request ARISSTO to dismantle the above stated product from my premises and agree to return the above stated product to ARISSTO.
I shall be liable to pay NEP for missing parts (if any) stated herein.　
本人谨此要求ARISSTO公司从我的住所拆除上述产品并同意退还给ARISSTO公司。我有责任缴付遗失零件费额（如有）。
(2) I agree to terminate my plan effective from the above plan termination date and agree to follow all the terms & conditions as stated
in the agreement. 本人同意终止我的计划，以上述终止计划日期即日生效，并同意遵守所有合约所规定的条款与细则。

Refund**by Sales Person/Dealer 经由销售员/代理退款**:

I hereby confirm the sales person/dealer has refunded me RM Cash Cheque No.
本人谨此确认，销售员/代理把款项退还予我 现金 支票(号码)
Refund**by ARISSTO 经由ARISSTO退款**:
I hereby request that the refund be paid to me 本人谨此要求退款支付方式:-
by bank transfer (Saving/Current Account)
通过银行转账 (储蓄/来往户口)
Bank Name
:
银行名
Payee (Name)
:
收款人 (姓名)
Bank Account No.
:
银行户口号码
**Refund is subject to non-occurrence of any event as per stipulated in the terms and conditions of the agreement. *退款根据合约所规定的条款和细则以非发生事故为准。

- -
Signature of the Customer 客戶签署 NRIC No. 身份证号码 Date 日期

Authorised Dealer/Service Consultant Particulars 授权代理/服务专员资料

Name H/P No.
姓名 手机号码
NRIC No. Code Signature & Chop
身份证号码 编号 签署与盖章

For Office Use 办公室专用

Technical Service Dept.
Received by RTL No. RTL编号: PCE No./PCE编号
技术服务部门
接收人
RO/Branch (Code) RPR/SIN No. (If any)
区域办公室/分店(编号) RPR/SIN 编号 (如有)
Issued by (Name) Signature & Chop 签署与盖章
批准人 (姓名) IRN No./IRN编号 Receive Date 接收日期:

Account Dept.(Name) Cancellation Amount IPP RM (IPP Approved Code

财务部门 (姓名) 取消数额 IPP 批准编号 )
Signature 签署
RPS RM (Banker 银行 )
Transaction Date 交易日期

White: Company copy Yellow: Authorised Service Person copy Green: Customer copy

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