Nurraysa (Test)

Reseller Registration

* Country

** Required Field

* State

* City

** Required Field

Sponsor Information (Leader)

* Username

* Sponsor ID

** Required Field

Sponsor Name

Applicant Information

* Applicant Name

** Required Field

* IC No. / Passport No.

** Required Field

Please do not insert "-" for IC No.

for commission payout purpose

* Handphone No

** Required Field Please Enter Telephone No Only

(eg.: xxxxxxxx)

* Email

** Required Field

(eg.: [email protected])

* Date Of Birth

** Required Field

Item		Package Code	Description	Unit Price	Quantity

Total Amount( ) : 0

Grand Total( ) : 0

Collect Mode :

Payment Information

	Payment Type	Payment Remarks	Payment Amount
1.

I declare that all the information is accurate and true to the best of my knowledge and I agree to abide and be bound by the

Terms and Conditions, Policies and Procedures, and Privacy Notice set forth in the application.

Reseller > Registration