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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*:
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:
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 No:
  Bank in Date:
Online Bank in to Account: 3063761618-Public Bank Berhad
  Bank in Date:
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: