V25082023

Product Application Form

Customer Details
Name of Customer :
NRIC/Passport/Company No. :
Email :
Contact Number :
Address :

Product(s) Details
Order Date :
Order No :
Outright Purchase/ :
Product Plan
Rental Period :
Warranty Period & :
Service & Maintenance :
Period
Product(s) :

Delivery/Installation :
Address

Delivery/Installation Date :

Outright Purchase Price :

Monthly Rental :
Early Termination Fee :
Total Loss Fee :
Advanced Fee :
Processing Fee :
Promotion Code :

I/We hereby declare that:

☐ I/We wish to outright purchase the Product(s) or subscribe to the Product Plan.
☐ The information provided by me/us is true and correct.
☐ I/We have read, accepted and agreed to be bound by the terms in GTCP, STCP and the above as well as any
amendments provided to you via email, SMS or CUCKOO+APP and the same shall be read together and considered as one
original and binding agreement between me/us and CUCKOO.
☐ I/We hereby consent to the collection and processing of my/our personal data in accordance with CUCKOO’S Privacy
Notice (at https://www.cuckoo.com.my/pdpa-consent). I/ We further agree and accept that the terms and conditions in
the CUCKOO’s Privacy Notice form an integral part of the terms and conditions of the outright purchase or Product Plan.

Signed by / on behalf of )
Name: )
NRIC No./Company No: )
)
________________________________________________
Name:
Title: