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Title:	Mr. Mrs. Miss. Dr. Prof.
First Name:
Last Name:
IC Number / ID Number / Passport Number:
Cell Phone Number - Write down your Country Code (for e.g. +673 for Brunei) if your Cell Phone No. is not registered in Malaysia:
2nd Person Name (those who join you during the car rental, or father, or sister, or your guardian, or etc):
2nd Person IC Number / ID Number / Passport Number (must supply a different IC Number / ID Number / Passport just in case of any emergency):
2nd Person Cell Phone Number (must supply a different Phone Number just in case of any emergency):
Email Address:
Working / Studying Address (only if you are not working / studying, write down your Home Address):
City:
State / Province:
Postal Code:
Country:
Driving Licence Number:
Issue Date (for e.g. 30/12/2013):
Expiry Date (for e.g. 30/12/2013):
Rental Type:	Self-Drive (Renting without a driver) Chaffeur (Renting with a driver) Student Fare (Renting without a driver. For student with a VALID Student ID / Matric Card ONLY)
Car Model (1st Option):	Perodua Kancil 660 EX (Manual) Perodua Kancil 660 EZ (Auto) Proton Wira Aeroback 1.3 GLS I (Manual) Proton Wira 1.5 GL (Auto) Perodua Viva 660 EX (Manual) Perodua Viva 850 EX (Manual) Perodua Viva 1.0 EZ (Auto) Perodua Viva 1.0 Elite (Auto) Perodua Myvi 1.3 SXI (Manual) Proton Saga 1.3 FL (Auto) Perodua Myvi 1.3 EZS (Auto) Perodua Alza - 1500 MPV (Auto) Toyota Unser 1.8 MPV (Auto) Honda Accord 2.0 (Auto) Toyota Alphard 2.4 MPV (Auto)
Car Model (2nd Option) - Only Applicable if the 1st Option Car is Not Available. Make sure the 2nd Option Car is a different car from the 1st Option Car:	Perodua Kancil 660 EX (Manual) Perodua Kancil 660 EZ (Auto) Proton Wira Aeroback 1.3 GLS I (Manual) Proton Wira 1.5 GL (Auto) Perodua Viva 660 EX (Manual) Perodua Viva 850 EX (Manual) Perodua Viva 1.0 EZ (Auto) Perodua Viva 1.0 Elite (Auto) Perodua Myvi 1.3 SXI (Manual) Proton Saga 1.3 FL (Auto) Perodua Myvi 1.3 EZS (Auto) Perodua Alza - 1500 MPV (Auto) Toyota Unser 1.8 MPV (Auto) Honda Accord 2.0 (Auto) Toyota Alphard 2.4 MPV (Auto)
Car Model (3rd Option) - Only Applicable if the 1st and 2nd Option Car are Not Available. Make sure the 3rd Option Car is a different car from the 1st and 2nd Option Car:	Perodua Kancil 660 EX (Manual) Perodua Kancil 660 EZ (Auto) Proton Wira Aeroback 1.3 GLS I (Manual) Proton Wira 1.5 GL (Auto) Perodua Viva 660 EX (Manual) Perodua Viva 850 EX (Manual) Perodua Viva 1.0 EZ (Auto) Perodua Viva 1.0 Elite (Auto) Perodua Myvi 1.3 SXI (Manual) Proton Saga 1.3 FL (Auto) Perodua Myvi 1.3 EZS (Auto) Perodua Alza - 1500 MPV (Auto) Toyota Unser 1.8 MPV (Auto) Honda Accord 2.0 (Auto) Toyota Alphard 2.4 MPV (Auto)
Car Usage (Location):	In Penang (Island area Only) In Penang (Island & Mainland Penang) Outside Penang (Please state the location you plan to go at the 'Remark' column below)
Pick Up Date (for e.g. 30/12/2013):
Pick Up Time (write either for e.g. 5.00PM or 17:00):
Pick Up Location (Other than 'Our Main Office' dan 'Our Branch', we will charge the delivery based on the distance between Our Main Office and your Pick Up Location. We will inform the charges when we send the price quotation):	Our Main Office (Lebuh Nipah 1, Sungei Nibong, Bayan Lepas 11900, Penang) Our Branch (Universiti Sains Malaysia / USM Main Campus) Our Branch (UiTM Pulau Pinang / Permatang Pauh) Alma Jawi Nibong Tebal Sungei Nibong Bus Terminal Butterworth Bus Terminal Sungai Ara Bayan Lepas Bayan Baru Queensbay Sungei Nibong Gelugor Jelutong Greenlane Ayer Itam Paya Terubong Padang Kota Lama Tanjong Tokong Tanjung Bungah Teluk Kumbar Pulau Tikus Gurney Georgetown Georgetown Jetty Penang International Airport Batu Feringghi Balik Pulau Butterworth Butterworth Jetty Bukit Mertajam Others (Please state the place or address at the 'Remark' column below)
Return Date (for e.g. 30/12/2013):
Return Time (write either for e.g. 1.00PM or 13:00):
Return Location (Other than 'Our Main Office' and 'Our Branch', we will charge the delivery based on the distance between Our Main Office and your Return Location. We will inform the charges when we send the price quotation):	Our Main Office (Lebuh Nipah 1, Sungei Nibong, Bayan Lepas 11900, Penang) Our Branch (Universiti Sains Malaysia / USM Main Campus) Our Branch (UiTM Pulau Pinang / Permatang Pauh) Alma Jawi Nibong Tebal Sungei Nibong Bus Terminal Butterworth Bus Terminal Sungai Ara Bayan Lepas Bayan Baru Queensbay Sungei Nibong Gelugor Jelutong Greenlane Ayer Itam Paya Terubong Padang Kota Lama Tanjong Tokong Tanjung Bungah Teluk Kumbar Pulau Tikus Gurney Georgetown Georgetown Jetty Penang International Airport Batu Feringghi Balik Pulau Butterworth Butterworth Jetty Bukit Mertajam Others (Please state the place or address at the 'Remark' column below)
Do you want to rent a GPS Navigator (RM10 / Day)?	Yes No
Remark:
To reserve your booking, you need to transfer RM10 or more (we will inform the exact amount after reviewing your Online Booking Form) to our Company Bank Account below: MAYBANK: 5574 3850 6655 (GLOBAL MATRIX ENTERPRISE) But you only transfer RM10 or more (we will inform the exact amount after reviewing your Online Booking Form) once you received the price quotation that we send to your email shortly.
We will contact you back shortly once you've submitted this form. Please check your email later on.. Thank You...

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