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NAME OF APPLICANT/COMPANY NAME *

TYPE BUSINESS REGISTRATION *

BUSINESS REGISTRATION NO. (AS PER SSM) *

SALUTATION *

CONTACT PERSON (NAME AS PER NRIC) *

Type of ID. *

NRIC/PASSPORT NO. *

DESIGNATION*

MOBILE NO. *

OFFICE NO. *

OFFICE FAX NO.

TARIFF CODE *

NATURE OF BUSINESS *

COMPANY ADDRESS

ADDRESS I *

ADDRESS II

ADDRESS III

POSTCODE *

CITY*

STATE*

COUNTRY *

PPM Contact

AGENT/OFFICER NAME *

State and Business nature is required

EMAIL ADDRESS (LOGIN)*

PASSWORD*

Password must be at least 8 characters contains numbers and characters.

CONFIRM PASSWORD*