Application Form
  Fields marked with * are mandatory
First Name*
Last Name*
Name to appear on card*
NIC Number - -
Date of Birth*
Gender*  
Email* (Enter your valid email)
Mobile No.*
Mailing Address*
City*
Tel Off
Tel Res
Preference of Communication Email  Mobile  Tel P.O. Mail
Education
Occupation
Name of Business/Profession
Designation
Number of Phones Purchased In Last 6 Months  
Favourite Restaurant
Favourite Sport
Phone Model Purchased*    
Date of Purchase*
 (As on warranty card )		   Year(yyyy)
Purchased From
(Shop Name & Address)		  
IMEI*
                                                       
                     Note:
                     Membership is valid on select mobile phones.                                             
   
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