AGENT REGISTRATION FORM

AGENT REGISTRATION FORM

MAZ HEALTH & BEAUTY (M) SDN BHD.
Registration *

Dropship Agen
Full Name *

First Name Last Name
Company Name
*If company existed
IC Number *
Date Of Birth *

Day Month Year
Date
home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
*If Company address and home address is same, left the company address blank
Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
Phone Number *

Area Code Phone Number
Start date

Day Month Year
Upload Identification card picture (IC) (front) *
Upload current Picture *
Should be Empty: