Agent Registration Form

Mahziman Agent Registration

Section 1 - Personal Information
Nama Penuh*
Email*
No Phone*
Alamat Premis*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Section 2 - Documents Upload
SSM*
Accepted file types: jpg, png, pdf.
Sila upload file SSM anda
Bank Letterhead*
Accepted file types: jpg, png, pdf.
Sila upload letterhead bank statement perniagaan anda. Letterhead hendaklah jelas menunjukan Nama Perniagaan anda, Alamat Premis, dan No Akaun Bank
IC*
Drop files here or

Accepted file types: jpg, png, pdf.
Sila upload IC anda Depan dan Belakang
Gambar Premis*
Drop files here or

Accepted file types: jpg, png, pdf.
Sila upload 3 (Tiga) gambar premis anda
Section 3 - E-Wallet Preference
E-Wallet*
- Boost
- Touch n Go
- GrabPay
Phone
This field is for validation purposes and should be left unchanged.

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