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Please complete the following application form and send to us.

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
Umobile
TuneTalk
itel

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.)