Customer Purchase Form (Johor - Batu Pahat)

PURCHASE ITEMS

(Outright Purchase)

Hydrogen Fountain 3 in 1

RM11,880.00 / unit

Portable Hydrogen Pot 2 in 1

RM3,880.00 / unit

Signal Port Faucet

RM1,500.00 / unit

Multi-purpose Ozone Bottle (MOB)

RM1,288.00 / unit

Water Sanitation System (WSS)

RM6,880.00 / unit

Space Sanitizer System (SSS)

RM3,360.00 / unit

(ACTIVE3 Plan)

Space Sanitizer System + 2 Years Service Plan

Year 1 Month 1&7: RM1,400
Year 2&3: RM80/month

Other

Quotation

PAYMENT METHOD

PAYMENT TYPE

CUSTOMER'S PERSONAL INFORMATION

Customer's Full Name as per Identity Card

FULL NAME AS PER IDENTITY CARD / PASSPORT

Mobile No

House Phone No.

Date of Birth

Gender

Male

Female

Marriage Status

Mailing Address

State

City

Postal Code

Email Address

BILLING INFORMATION

Same as Above

Company Name

Company Registration Number

Office Phone No.

Mailing Address

State

City

Postal Code

Email Address

DELIVERY METHOD

Delivery Method

INSTALLATION / DELIVERY ADDRESS

Address

State

City

Postal Code

REMARK (IF ANY)

REMARK / REMINDER

AMBASSADOR INFORMATION (IF ANY)

AMBASSADOR'S NAME

AMBASSADOR ID (BXXXXXXX)

Biolux Network (Asia) Sdn Bhd shall ensure that the collection, use and disclosure of your personal data is consistent with the Malaysian Personal Data Protection Act 2010 ('PDPA') and the relevant Privacy Laws in place in each jurisdiction that Biolux Network (Asia) Sdn Bhd operates in. It is acknowledged that personal data collected and processed is obtained voluntarily and with your consent
Biolux Network (Asia) Sdn Bhd akan memastikan bahawa pengumpulan, penggunaan dan pendedahan data peribadi anda adalah konsisten dengan Akta Perlindungan Maklumat Peribadi Malaysia 2010 ('PDPA') dan undang - undang Privasi yang releven Privacy Laws relevan di bidang kuasa Biolux Network (Asia) Sdn Bhd. Dengan ini diakui bahawa data peribadi yang diperolehi serta diproses adalah secara sukarela dan dipersetujui oleh anda.

I hereby confirm that all the information given is correct and I am of age 18 and above, I agree to be bound by the terms and conditions above.
Saya dengan ini mengaku bahawa segala maklumat diatas adalah benar dan saya berumur 18 tahun dan keatas. Saya bersetuju dikenakan sebarang tindakan jika melanggar syarat-syarat yang telah ditetapkan tertera borang ini.

THIS CONTRACT IS SUBJECT TO A COOLING-OFF PERIOD OF 10 WORKING DAYS

By click the button I Agree for the terms and conditions above.