Celcom Home New

Celcom Home New Package Information
* For foreigner will need to additional collect RM100 for deposit.

Package (required)

—Please choose an option—Data + ModemC-Broadband Pro (10GB)(Data + Modem)@RM146.28C-Broadband Advance (6GB)(Data + Modem)@RM103.88C-Broadband Basic (4GB)(Data + Modem)@RM72.08C-Broadband Lite (1.5GB)(Data + Modem)@RM50.88Data OnlyC-Broadband Pro (10GB)(Data Only)C-Broadband Advance (6GB)(Data Only)C-Broadband Basic (4GB)(Data Only)C-Broadband Lite (1.5GB)(Data Only)

Principle Mobile No

Supplementary Mobile No

Celcom Home New Applicant Information

Applicant Name (required)

NRIC or Passport No (required)

Gender

MaleFemale

Home Address (required)

Postcode (required)

Home Contact No

Mobile Contact No

Nationality

MalaysianNon Malaysian

Email

Race

ChineseMalayIndian

Mother Maiden Name

Preferred Contact Channel

MailE-mailOffice PhoneMobile

Occupation

Employer

Office Address

Office Address

Office Contact No

Office Fax No

Language

EnglishBahasa Malaysia

Celcom Home New Billing InformationSame as Installation Address

Address

Itemised Billing

YesNo

Directory Listing

YesNo

Credit Card Payment

YesNo

Reference

Reference Name (required)

Relationship

FriendParentBrotherSisterPartnerWifeHusbandOther

Reference Home Contact No

Reference Office Contact No

Reference Mobile No

Additional Information

Dealer Remarks

Supporting Documents (Max 1mb gif png jpg jpeg)(Void for Celcom use)

NRIC Front or Passport (required)

NRIC Back

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