EmailMe Form - Application Form for Streamyx HOME

Are you have telephone line: *

YES

NO

If YES, what is the number:

Are you want use this telephone line for Streamyx ?:

YES (I want use this telephone line for Streamyx)

NO (I want add new telephone line for Streamyx)

Note : If you have telephone line and want use this line for streamyx, applicant name must same with telephone-line register name.

Streamyx Package: *

Please refer http://telecomninterestonlinebm.blogspot.com/ for the packages.

Preffered LoginID 1: *

5-8 Characters. xxxxx@streamyx.com

Preffered LoginID 2: *

5-8 Characters. xxxxx@streamyx.com

Preffered LoginID 3: *

5-8 Characters. xxxxx@streamyx.com

Name of Applicant : *

* must same with NRIC

Applicant IC No: *

(Example: 721010145243)

Applicant Old IC No:

(This is required if applicant born in 1977 or before 1977)

Mobile Number : *

Contact Email : *

Installation Address : *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please fill (-) for empty space. Must same with TNB address bill.

Copy of Applicant NRIC : *