Registration Fee is RM 50.00
Please fill in the following form and submit.Required fields are marked with * sign.You can get the member rate after registered.

Applicant's Information / Maklumat Pemohon:

Name / Nama*:

Old IC No. / No. KP Lama:

New IC No. / No. KP Baru*:

Sex / Jantina*:

Date of Birth / Tarikh Lahir*:

(dd/mm/yyyy)

Nationality / Warganegara*:

Address / Alamat*:

House Tel No. / No. Tel Rumah:

Office Tel No. / No. Tel Pejabat:

Handphone No / No Telefon Bimbit:

Fax No. / No. Fax:

Email:

Race / Bangsa:

Sponsor Information / Penaja Maklumat:

Direct Referral Name / Nama Rujukkan Terus:

Distributor ID / ID Pengedar:

NRIC / No. KP:

Product Order / Tempahan Produk:

QTY	CODE	PRODUCT NAME	VOLUME	PRICE
	M6	Minatures bottle	6 ML	RM 32
	M6-71	7 Miniatures in 1 box	7 x 6 ML	RM220
	C30	Frosted canister bottle with pump	30 ML	RM 150
	R30	Refill bottle	30 ML	RM 120
	C50	Frosted canister bottle with pump	50 ML	RM 250
	MT001	Presentation and Testimony VCD	1 PC	RM 5
	MT002	Leaflets	10 PCS	RM 2
	MT004	Receipt book	1 PC	RM 5
	MT005	Application form (50 pcs)	50 PCS	RM 30
	MT006	Psynergy logo pin	1 PC	RM 5

I will pick up personally / Saya akan ambil sendiri

Please ship to / Sila hantar kepada:

We'll charge RM12.50 for shipment around Malaysia.

Mode of Payment / Cara Bayaran:

	Cheque:
	Cheque No:
	Bank in Date:
	Branch:

	Online Bank in to Account:	3063761618-Public Bank Berhad
	Amount(RM):
	Bank in Date:
	Branch:

	Credit Card:
	Cardholder Name:
	Card No:
	Expiry Date:	*We'll charge 3% of the total price.

Beneficiary / Pewaris:

Name / Nama:

IC No. / No. KP

Relashionship / Hubungan: