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Mobile Services Information - page 1 / 3

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Subscriber Registration

Mobile Services Information

SIM Serial No.

Mobile Number

(For MNP only)

New Telephone Number

Referral Information

Branch Code

Service Center Code

Referral Mobile

Referral NRIC

Referral Member ID

Applicant Information

Salutation

Member ID

Name

Nationality

Gender

NRIC Number

Old NRIC/Passport/Police ID / Army ID

Race

Date of Birth

(mm/dd/yy)

Present Contact Number

Address

Postcode

Town

State

Email

Bank A/C Number

Bank Name

Branch

Beneficiary Information

Name

NRIC Number

Old NRIC/Passport/Police ID / Army ID

Contact Number

Relationship

Declaration

By Applicant.

I hereby declare that the above information given is true and complete. I have read, understand and agree to be bound by the Terms & Conditions overleaf. I also agree to be severally liable for all fees, charges and expressly acknowledge and agree to any monies forfeiture in accordance to WOW! Membership Programme.

By Referrer.

I hereby confirm that the Applicant’s details in this application have been verified at Point-Of-Sale and I agreed to be bounded by all terms and conditions overleaf.

……………………………………………………………………

Applicant Signature

Dated

/

/

……………………………………………………………………

Referrer Signature

Dated

/

/

For Office Used Only

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