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Retailers Application Form

* Required Field


Company Name *
Registration No. *
Type of Business *
Correspondence Information
Title
Contact Person *
Address Line 1 *
Address Line 2
State *
Postcode *
Country *
Tel. No .*
Fax. No.
Email
Invoicing / Billing Contact Information
Title
Contact Person *
Address Line 1 *
Address Line 2
State *
Postcode *
Country *
Tel. No *
Fax. No
Email
Standard Hours of Business
Monday *		From to
Tuesday *		From to
Wednesday *		From to
Thursday *		From to
Friday *		From to
Saturday *		From to
Sunday *		From to
Forecast Weekly Voucher Sales by Network - Value in RM
Digi
Celcom
Maxis
Mobikom
TMTouch
Adam
Terminals
No. of Terminals Required *
Authorized Location
Address Line 1 *
Address Line 2
State *
Postcode *
Country *
Retailer Name *
Location *
Person In Charge *
Title
Tel. No *
Fax. No
Email

TERMS & CONDITIONS

The terminal(s) is/are always located at the authorized location.
The sales/voucher price is in accordance with what is set on the menu/LCD.
The retailer is fully responsible for the assigned Administrator code and shall safeguard it from any unauthorized access.
Risk and title of the PINs is passed to the retailer once the voucher is printed.
No other paper is allowed except those supplied by e-pay (M) Sdn Bhd.(494207 U)
Excessive wastage of paper over the standard ordering cycle will be charged.
Terminal(s) will always remain the property of e-pay (M) Sdn Bhd and e-pay (M) Sdn Bhd reserve the right to recall the terminal(s) whenever deemed necessary.
In the event of damaged or lost of a terminal, the retailer is required to compensate RM2,000.00 to e-pay (M) Sdn Bhd.
Payment is to be made immediately upon receipt of invoice(s).
(Fax copies are to be recognized as original.)

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