MPV NAZA RIA FOR RENTAL

No. 29, Jalan SP3/2, Taman Seri Pristana,

47000 Sungai Buloh, Selangor Darul Ehsan.
Tel: 019-2739844 Email: millionemail@gmail.com
Rental Application Form
A) NAZA RIA DRIVER INFORMATION
Name : SHAMSHUDDIN BIN MOHAMAD DAHAM
Identification Card No. : 591003-08-5845 Reminder
Address : LOT 8, LRG. LAPANGAN TERBANG 2A1
: GREEN HEIGHTS, 93250 KUCHING, SARAWAK Pls attach with Photocopy
Home Tel. : 082-455979 IC/LICENCE/UTILITES Bill &
Mobile Phone :019-8177605 Cross “ For Rental Only”
Date of Birth :
Age : 50 TAHUN
:
Email :shamsh@streamyx.com

Profession/Occupation :
Company & Address :
Office Tel. :
Fax :
B) DESTINATION INFORMATION
Destination :KLIA
Rent Date From : 18hb. September 2009
Delivery Date To : 25hb September 2009
Purpose For : Social
C) NAZA RIA MPV INFORMATION ( For Officer Only.Dont Fillup)
Car Registration No. : Year of Manufacture:
Model : Chasis No. :
Engine No. : Registration Date :
Color :
PRICE RENTAL :
D) INTRODUCER, TERM AND CONDITION

Introducer
1) Name: Membership No.:
2) Name: Membership No.:
Terms and Conditions
1. Booking registration fee of RM100; Bank in to Maybank Acc : MOHD NASRAH MOHD IDRIS 114011389647
2. Please attach photostate IC,Drivimg Licence.Utilities Bill fees, with this completed rental application form To
nominate a legal representative of the owner of the vehicle to be a member, please sign below:

Signature: __________________________ CompanyStamp:

____________________________________
(For Company Only)
F) APPLICANT’S DECLARATION
I hereby declare that the information above is correct. I would also abide all the rental rules and regulations.

Signature: __________________________ Date :