Gender:

Male Female

First Name:

_____________________________________________________

Last Name:

_____________________________________________________

Date of Birth:

_____________________________________________________

E-Mail Address:

_____________________________________________________

Address:

_____________________________________________________

_____________________________________________________

_____________________________________________________

Post Code:

_____________________________________________________

City:

_____________________________________________________

State:

_____________________________________________________

Country:

_____________________________________________________

Contact

_____________________________________________________

Telephone Number:

_____________________________________________________

Mobile Phone:

_____________________________________________________

Fax Number:

_____________________________________________________

Special Instructions:

_____________________________________________________

_____________________________________________________

_____________________________________________________

Direct/Transfer Payment Payable to:
HOUSE OF PRIDE SDN BHD

Malayan Banking Berhad Account No.: 5123 1651 3149
Public Bank Berhad Account No.: 3134 94 6022

Please fax the Bank In Slip together with this forms to:
(603) 7713 2408

Please contact cservice@ho-pride.com if you need any further assistance