SERVICE REGISTRATION FORM

Requirements
1. Corporate Official- Malaysian Company-Photocopy of Form 24, 49 & Form 9 or 13.Foreign Company-Photocopy of Form 79 or 80 or 80A or
83 or 83A. Sole Proprietor/Partnership-Photocopy of Form D & A or Form D & B.
2. Corporate Employee - NRIC/MyKad/Passport and Business Card with Business Registration Number.
3. Personal - Photocopy of NRIC/MyKad/Passport.

Instruction
1. Please write in Block LETTERS
2. Tick where applicable
3. *Mandatory fields
4. **Required Fill Up By Dealer

A. Type Of Segment Corporate C.For New Customer

B. For Existing Customer ( Account Details ) Documents Required

For Corporate/Company : *To be certified with company Stamp
Customer/Company Name
Photocopy of authorised signatory's NRIC (both side) or passport (Non-Malaysian)
BRN No

NRIC/Mykad/Passport No

Contact Number Photocopy of authorised Company Registration documents*

Company Address

D. Personal/Corporate Employee Information

Tittle Others *Date Of Birth

*Name *Race : Please Select Others

(as in NRIC/MYKad/Passport)

*MyKad *Billing Address

*Old NRIC/Passport No./Others

Alternate Contact No

*Email Address Postcode

*Mother's Maiden Name

*Company Name

BRN

E. Company Details
Company Name Contact Person For Enquiries
(as per company Form)
Name

Business Registration No Designation

Registered Address Contact Number (Office)

Email

Nature of Business Billing Address

Authorised/Paid Up Capital
Authorised Signatory Name

Designation Postcode

MyKad Authorised Signatory Email

Old NRIC/ Passport No./Others

Contact Number (Office)

F. Billing Preference

Language Bahasa Malaysia Billing Type E-Billing OCS

Pay Your Way

Via Auto Payment 1 Summary Billing

Please Select
Type Of Credit Card : Itemised Billing

Issuing Bank : E-Billing (For Company Only)

Name on Credit Card:

Credit Card/
Bank Account No.

Expiry Date:

Note: Auto Payment is eligible for card issued by local Banks. Customer using a Third party's credit card must submit an original authorization letter by the credit cardholder.
G. Service Package

Line 1 Line 2 Line 3 Line 4 Line 5

1 Master Number

2 Mobile Number 019-2320341

3 Type of Registration CRP Please Select Please Select Please Select Please Select

4 Billing Itemized Billing Please Select Please Select Please Select Please Select

5 CUG

First Platinum Business Please Select Please Select Please Select Please Select
6 Package Plan

7 Package Details First Platinum Business Please Select Please Select Please Select Please Select

8 Monthly Commitment 148 Please Select Please Select Please Select Please Select

9 Contract Duration 24 Months Please Select Please Select Please Select Please Select

10 Early Termination RM1,000 Please Select Please Select Please Select Please Select

11 Supplementary Info

12 Account Type SINGLE

13 Billing Type BILLED

14 Mobile Internet Plan

15 Data Package/ Additional Data

International Roaming/ M2M (Voice

16
& SMS)

17 International Roaming/ M2M (Data)

18 User's Name AHA TIGA TIGA ENTERPRISE

19 NRIC/Mykad/Passport No 921117-06-5577

For Port-In : Donor

(Existing Operator)

Donor Account No
20

Company's BRN/ Donor NRIC

Credit Limit

Advance/ Upfront Payment For Plan

21
Subscribtion

22 Deposit

Value Added Services (VAS) PLEASE SELECT PLEASE SELECT PLEASE SELECT PLEASE SELECT PLEASE SELECT

23

24 SIM Card Serial No

25 OMNI PACKAGE Prefered User Name: Channel to Subscribe : (Please Tick)

SMS EMAIL Voice Messaging Push Notification

Chat Application (Please Choose Type Of Chat Application Below)

Facebook messenger Viber Line Telegram

H. Customer Declaration

I hereby declare that :

• The information given above is true and accurate to the best of my knowledge
• I have read, understood and agree to be bound by the respective Terms and Conditions for each service and am liable for all fees and charges incurred for the respective service
• I agree that by executing the Registration Form or by continuing to use the service, I am giving consent to Celcom that the information collected by Celcom from me
('Personal Information') will be used and /or disclosed in accordance to Celcom's Privacy Notice as posted on its website at (https://www.celcom.com.my/personal/policy) and
personal
Data Protection Act 2010. I agree to read Celcom's Privacy Notice to understand my right with regards to my Personal Information
• I agree to provide additional information/documentation as and when requested by Celcom
• I hereby declare that I am not a declared bankrupt nor is there any proceeding of the same nature being initiated against me
• I hereby confirm that I have read, clearly understood and agree to the aforesaid Terms and Conditions as stated on Celcom's website at www.celcom.com.my

Signature*

Date*

Time*

Company Stamp and Business Registration Number only*

I. For Office Use Only

Device And Payment Information

SO Type

Batching No

ES001 ES003 ES004 ES005 ES006 ES007

SAP IO
HQ NORTHERN EASTERN SOUTHERN SABAH SARAWAK

Receipt No

**PO/ Memo Ref No

**Company Name / Customer Code

**BRN Number

**Delivery Address

**Receiver Name **Contact Number

Device Payment Mode ( Please Circle )**

Please Select
Device Brand /
No Mobile Number** Model/ Material Code** Qty**
Device Price including
Color** 6% GST
Device Price before GST (RM)** GST Chq/Cr Card No** Bank Name**
(RM)**
(RM)**

HUAWEI NOVA 3I
1 0129082488 1 RM0.00 RM0.00 RM0.00
BLACK 20010785

TOTAL RM0.00 RM0.00 RM0.00

SITI MUJAHIDAH NAFISAH BINTI AHMAD 40

**Account Manager Name **Segment Code

**Account Manager ID ETN00036

Credit Treatment Code 06

**Dealer Code Servicing Code

Pairing Outlet TEMERLOH BRANCH **Bill Cycle

Checked & Verified By Promo Code

Initial

Date of Verification **Dealer's Stamp

G. Service Package

Line 1 Line 2 Line 3

1 Master Number

2 Mobile Number

3 Type of Registration Please Select Please Select Please Select

4 Billing Please Select Please Select Please Select

5 CUG

Please Select Please Select Please Select

6 Package Plan

7 Package Details Please Select Please Select Please Select

8 Monthly Commitment Please Select Please Select Please Select

9 Contract Duration Please Select Please Select Please Select

10 Early Termination Please Select Please Select Please Select

11 Supplementary Info
11 Supplementary Info

12 Account Type

13 Billing Type

14 Mobile Internet Plan

15 Data Package/ Additional Data

International Roaming/ M2M (Voice

16
& SMS)

17 International Roaming/ M2M (Data)

18 User's Name

19 NRIC/Mykad/Passport No

For Port-In : Donor

(Existing Operator)

Donor Account No
20

Company's BRN/ Donor NRIC

Credit Limit

Advance/ Upfront Payment For Plan

21
Subscribtion
22 Deposit

23 Value Added Services (VAS) PLEASE SELECT PLEASE SELECT PLEASE SELECT

24 SIM Card Serial No

 Line 4 Line 5

Please Select Please Select

Please Select Please Select

Please Select Please Select

Please Select Please Select

Please Select Please Select

Please Select Please Select

Please Select Please Select

PLEASE SELECT PLEASE SELECT
 TYPE OF
Component MOBILE NUMBER REGISTRATION BILLING CUG PACKAGE PLAN PACKAGE DETAILS

LINE 1 CRP ITEMIZED BILLING

LINE 2 P2P

LINE 3 CRP ITEMIZED BILLING

LINE 4 CRP

LINE 5 CRP ITEMIZED BILLING

LINE 6 CRP ITEMIZED BILLING

LINE 7 CRP ITEMIZED BILLING

LINE 8 CRP ITEMIZED BILLING

LINE 9 CRP ITEMIZED BILLING

LINE 10 CRP PLEASE SELECT

LINE 11 CRP ITEMIZED BILLING

LINE 12 CRP ITEMIZED BILLING

LINE 13 CRP ITEMIZED BILLING

LINE 14 CRP ITEMIZED BILLING

LINE 15 CRP ITEMIZED BILLING

LINE 16 CRP ITEMIZED BILLING

LINE 17 CRP ITEMIZED BILLING

LINE 18 CRP ITEMIZED BILLING

LINE 19 CRP ITEMIZED BILLING

LINE 20 CRP ITEMIZED BILLING

LINE 21 CRP ITEMIZED BILLING

LINE 22 CRP ITEMIZED BILLING

LINE 23 CRP ITEMIZED BILLING

LINE 24 CRP ITEMIZED BILLING

LINE 25 CRP ITEMIZED BILLING

LINE 26 CRP ITEMIZED BILLING

LINE 27 CRP ITEMIZED BILLING

LINE 28 CRP ITEMIZED BILLING

LINE 29 CRP ITEMIZED BILLING

LINE 30 CRP ITEMIZED BILLING

 DATA PACKAGE/ADDITIONAL INTERNATIONAL ROAMING INTERNATIONAL
SUPPLEMENTARY INFO ACCOUNT TYPE MASTER NUMBER BILLING TYPE MOBILE INTERNET PLAN DATA (VOICE & SMS) ROAMING (DATA) USER'S NAME

SINGLE UNBILLED

CHILD UNBILLED

MASTER UNBILLED

CHILD UNBILLED

MASTER UNBILLED

MASTER UNBILLED

SINGLE UNBILLED

SINGLE UNBILLED

CHILD UNBILLED

MASTER UNBILLED

CHILD UNBILLED

SINGLE UNBILLED

SINGLE UNBILLED

CHILD UNBILLED

CHILD UNBILLED

CHILD UNBILLED

MASTER UNBILLED

SINGLE UNBILLED

MASTER UNBILLED

CHILD UNBILLED

SINGLE UNBILLED

MASTER UNBILLED

SINGLE UNBILLED

CHILD UNBILLED

BILLED

MASTER BILLED

CHILD PLEASE SELECT

CHILD UNBILLED

MASTER BILLED

SINGLE BILLED
 For Port-In :
DONOR (EXISTING DONOR ACCOUNT NO COMPANY'S BRN/DONOR NRIC CREDIT LIMIT SIM CARD SERIAL NO
OPERATOR)
Component MASTER NUMBER MOBILE NUMBER TYPE OF BILLING CUG PACKAGE PLAN PACKAGE DETAILS MONTHLY COMMITMENT CONTRACT EARLY
REGISTRATION DURATION TERMINATION

WITH SMS
LINE 1 CRP ITEMIZED BILLING 8 12 Months
M2M-8 W/O SMS
WITH SMS
LINE 2 P2P W/O SMS 8 12 Months
M2M-8
WITH SMS
LINE 3 CRP ITEMIZED BILLING W/O SMS 8 12 Months
M2M-8
N/A
LINE 4 CRP 138 12 Months
M2M-138 W/O SMS
WITH SMS
LINE 5 CRP ITEMIZED BILLING W/O SMS 25 12 Months
M2M-25
WITH SMS
LINE 6 CRP ITEMIZED BILLING W/O SMS 35 12 Months
M2M-35
LINE 7 CRP ITEMIZED BILLING N/A 180 12 Months
M2M-180 W/O SMS

LINE 8 CRP ITEMIZED BILLING WITH SMS 50 12 Months

M2M-50 W/O SMS
WITH SMS
LINE 9 CRP ITEMIZED BILLING 25 12 Months
M2M-25 W/O SMS

LINE 10 CRP ITEMIZED BILLING N/A 138 12 Months

M2M-138 W/O SMS

LINE 11 CRP ITEMIZED BILLING WITH SMS 25 12 Months

M2M-25 W/O SMS
WITH SMS
LINE 12 CRP ITEMIZED BILLING 8 12 Months
M2M-8 W/O SMS

LINE 13 CRP ITEMIZED BILLING WITH SMS 35 12 Months

M2M-35 W/O SMS

LINE 14 CRP ITEMIZED BILLING WITH SMS 50 12 Months

M2M-50 W/O SMS
WITH SMS
LINE 15 CRP ITEMIZED BILLING W/O SMS 35 12 Months
M2M-35
LINE 16 CRP ITEMIZED BILLING WITH SMS 25 12 Months
M2M-25 W/O SMS

LINE 17 CRP ITEMIZED BILLING N/A 138 12 Months

M2M-138 W/O SMS
N/A
LINE 18 CRP ITEMIZED BILLING W/O SMS 250 12 Months
M2M-250
N/A
LINE 19 CRP ITEMIZED BILLING 220 12 Months
M2M-220 W/O SMS

LINE 20 CRP ITEMIZED BILLING Celcom Business FREE 50 Lines RM4,500 24 months
L Plan
N/A
LINE 21 CRP ITEMIZED BILLING W/O SMS 180 12 Months
M2M-180
WITH SMS
LINE 22 CRP ITEMIZED BILLING 8 12 Months
M2M-8 W/O SMS
N/A
LINE 23 CRP ITEMIZED BILLING 138 12 Months
M2M-138 W/O SMS
N/A
LINE 24 CRP ITEMIZED BILLING 220 12 Months
M2M-220 W/O SMS

LINE 25 CRP ITEMIZED BILLING WITH SMS 8 12 Months

M2M-8 W/O SMS

LINE 26 CRP ITEMIZED BILLING N/A 250 12 Months

M2M-250 W/O SMS
N/A
LINE 27 CRP ITEMIZED BILLING 138 12 Months
M2M-138 W/O SMS

LINE 28 CRP ITEMIZED BILLING N/A 180 12 Months

M2M-180 W/O SMS

LINE 29 CRP ITEMIZED BILLING WITH SMS 50 12 Months

M2M-50 W/O SMS
WITH SMS
LINE 30 CRP ITEMIZED BILLING W/O SMS 50 12 Months
M2M-50
SUPPLEMENTARY INFO ACCOUNT TYPE BILLING TYPE MOBILE INTERNET PLAN DATA PACKAGE/ADDITIONAL INTERNATIONAL ROAMING INTERNATIONAL USER'S NAME NRIC / Mykad / Passport
DATA (VOICE & SMS) ROAMING (DATA) as per IC/Mykad/Passport NO

MASTER UNBILLED

UNBILLED

MASTER UNBILLED

CHILD UNBILLED

MASTER UNBILLED

MASTER UNBILLED

SINGLE UNBILLED

SINGLE UNBILLED

CHILD UNBILLED

MASTER UNBILLED

CHILD UNBILLED

SINGLE UNBILLED

SINGLE UNBILLED

CHILD UNBILLED

CHILD UNBILLED

CHILD UNBILLED

MASTER UNBILLED

SINGLE UNBILLED

MASTER UNBILLED

CHILD UNBILLED

SINGLE UNBILLED

MASTER UNBILLED

SINGLE UNBILLED

CHILD UNBILLED

BILLED

MASTER BILLED

CHILD PLEASE SELECT

CHILD UNBILLED

MASTER BILLED

SINGLE BILLED
 For Port-In :
DONOR (EXISTING DONOR ACCOUNT NO COMPANY'S BRN/DONOR NRIC CREDIT LIMIT ADVANCE/ UPFRONT SIM CARD SERIAL NO
PAYMENT
OPERATOR)

#REF!

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#REF!
 Device Brand /
No Mobile Number Model/ Material Code
Color

10

11

12

13

14

15

16

17

18

19

20

TOTAL
 Device Pay

Qty
6% GST
Device Price before GST (RM)
(RM)
 Device Payment Mode ( Please Circle )
Please Select

Device Price including GST

Chq/Cr Card No
(RM)
Bank Name
PACKAGE REGISTRATION DETAILS
(TO BE FILLED BY CUSTOMER)

2G SIM
PACKAGE
GPRS up to 128kbp

M2M LTE ROUTER SERIES – H1

M2M-8 – DATA ONLY (WITH SMS)
M2M-8 – DATA ONLY (W/O SMS)
M2M-8 – VOICE AND DATA
M2M-25 – DATA ONLY (WITH SMS)
M2M-25 – DATA ONLY (W/O SMS)
M2M-25 – VOICE AND DATA
M2M-35 – DATA ONLY (WITH SMS)
M2M-35 – DATA ONLY (W/O SMS)
M2M-35 – VOICE AND DATA
M2M-50 – DATA ONLY (WITH SMS)
M2M-50 – DATA ONLY (W/O SMS)
M2M-50 – VOICE AND DATA
M2M-138 DATA ONLY (W/O SMS)
M2M-180 DATA ONLY (W/O SMS)
M2M-220 DATA ONLY (W/O SMS)
M2M-250 DATA ONLY (W/O SMS)
M2M-500-VOICE AND BULK DATA
M2M-500-BULK DATA ONLY
M2M-1200-VOICE AND BULK DATA
M2M-1200-BULK DATA ONLY
M2M SMS FLAT

Selection of M2M Package and speed (Please tick √ below)

ADD ON SERVICE SELECTIONS

•Simcard’s IP will be re-cycled (Dynamic) and shared w

DEFAULT APN APN: m2m.celcom.net.my
•ABLE to browse internet

Access Point Name (max 12 alphan

•Simcard’s IP will change, within specific range

DEDICATED APN Private Dynamic IP
•NOT ABLE to browse internet
•Simcard’s IP will retain, within specific range
Private Fixed IP
•NOT ABLE to browse internet

IP 4 IP 8 IP 16 IP
PRIVATE FIXED IP IP Blocks
# Block

•Simcard’s IP will retain, within specific range

PUBLIC FIXED IP APN: im2m
•ABLE to browse internet
 Product Name

Monthly recurring M2M TOP UP (10MB) Auto Renew

M2M TOP UP (to enable at M2M TOP UP (100MB) Auto Renew
Combo Package)
M2M TOP UP (500MB) Auto Renew
M2M TOP UP (1GB) Auto Renew
M2M Top Up (One Off) products can only be subscribed via Self Care

Product Name
Monthly recurring M2M ROAMING 15
M2M ROAMING (to enable at
M2M ROAMING 25
Combo Package)
M2M ROAMING 35
M2M ROAMING PPU
 2G SIM 3G SIM
GPRS up to 128kbps 3.5G up to 21Mbps

N/A

SELECTIONS

ed (Dynamic) and shared with other M2M users

(max 12 alphanumeric character ONLY- 1 word)

thin specific range

et
hin specific range
et

32 IP 64 IP 128 IP 256 IP

hin specific range

ct Name Select
0MB) Auto Renew
00MB) Auto Renew
00MB) Auto Renew
1GB) Auto Renew
only be subscribed via Self Care Portal

ct Name Select
AMING 15
AMING 25
AMING 35
AMING PPU