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   * Mandatory Fields
1. PERSONAL INFORMATION
Title/Salutation
First Name *
Please enter your first name.
Last Name *
Please enter your last name.
Email Address *
Please enter a valid email address.
Preferred Name in Communication *
Please enter a preferred name. We will use this name in all communications.
Gender *
Race *
Type of Identification *
Identification Number *
Please enter your identification number based on the identification type selected earlier.
Example: 740929-01-xxxx
Date of Birth *     
Address 1 (Street) *
Please enter your address.
Address 2 (Street)
Please enter address line 2 (if applicable).
Address 3
Please enter address line 3 (if applicable).
City *
Please enter your city name.
State *
Post Code *
Please enter your Zip / Postal Code.
Country *
Malaysia
Country is set by the System and cannot be changed.
Mobile Phone Number *
Please enter your mobile phone number. Example: 01X-XXXXXXX
 
2. Promotional Information:
Please check on the boxes if you do not wish to receive any of the communications below.
CLUB Panasonic electronic newsletter
CLUB Panasonic events
CLUB Panasonic campaign & promotions
CLUB Panasonic surveys & questionnaires
CLUB Panasonic short messaging service (SMS)


I have read and agreed on the Terms and Conditions. I also agree to receive a monthly e-point electronic statement from CLUB Panasonic. *