Service Application Form

Business Services Reg. No. 201117683C

□ New Subscription □ Modification □ Recontract □ Others

Existing Customer Number:

Business Customer Information

Company Details Authorised Officer Particulars

Name of Business / Company as in ACRA: Name of Authorised Officer, as in NRIC / Passport / FIN:
(Mr/Miss/Mrs/Mdm/Dr)

Business Registration Number (BRN): Designation:

Registered Address as in ACRA: NRIC / Passport/ FIN of Authorised Officer:

Postal Code: Date of Birth (DD/MM/YYYY):

Company Contact Numbers: Contact Details of Authorised Officer

Main Office Contact Number: Office Number:

Mobile Number:

Main Office Fax Number: Email Address:

Installation Details

Installation Address: □ check here if same as Registered Address Request for Service (RFS) Activation Date: ____ /____ /________
(DD/MM/YYYY)
I confirm that the installation premises is not under renovation
and is ready for service installation and activation.
□ Yes
□ No, it would be ready by ____ /____ /________ (DD/MM/YYYY) for
site survey
Note: Cancellation charges apply if there is any change to the
installation address and RFS date once we have accepted your
Postal Code: application.

Billing Details

Billing Address: □ check here if same as Registered Address Name of Billing Contact Person, as in NRIC / Passport / FIN:

Contact Details of Billing Contact

Office Number:

Mobile Number:

Postal Code: Email Address:

Payment Mode

Payment By □ Credit Card 1 □ Debit Card □ GIRO 2 □ CHEQUE

If you're paying by credit or debit card, your payment information will be collected via our electronic payment link when your order is
being processed. An SMS will be sent to you with the electronic payment link for your necessary input of credit / debit card details.
If you're paying through GIRO, please attach the Bank GIRO Application Form.

1 Customer must give seven (7) days notice to MyRepublic if credit card details are to change.
2 Must attach a completed and signed GIRO form, otherwise no installation will be carried out.

Please provide the following documents with your application:

1. Document that supports incorporation of the entity, e.g. company’s latest Certificate of Registration from the Accounting and Corporate Regulatory
Authority of Singapore (ACRA)
2. Copy of identification document (NRIC/ FIN/ Passport) of the Authorised Officer who is applying on behalf of the company, for authentication purposes
3. Original letter of authorization with company’s letterhead indicating name, NRIC, designation of Authorised Officer, and signed by the company
Director (with Company Stamp) if the Authorised Officer is not the owner or director of the company
4. Proof of billing address, if applicable

MyRepublic Service Application Form – Business Services E-48-03-140120 Page 1 of 3

 Service Description

Description: OTC MRC

Service Package

Contract Length □ 24 Months □ 36 Months □ Other (please specify): _____________________

Total Charges (Before GST)

Total Charges (After GST)

Additional Service Remarks:

Please attached accepted Quotation for the Services.

General Service Terms & Conditions

1. All Services are provided subject to the MyRepublic Business General Terms and Conditions and MyRepublic Policies as set out in https://myrepublic.net/sg/legal/
business-enterprise. In addition, the below detailed Specific Terms and Conditions/Service Level Agreements shall apply and copies can be obtained from the Account
Manager or MyRepublic website.

2. MyRepublic shall endeavour to deliver your Services by RFS date, subject to our service provisioning lead times and applicable Specific Terms and Conditions.

3. All Charges quoted are subject to change according to the MyRepublic's General Terms and Conditions.

4. Charges do not include GST or any other applicable sales or use tax or similar charge, unless otherwise stated.

5. For after-sales enquiries or support,you may contact:

5.1 your Account Manager for Service Provisioning, change of Service plans, or renewal matters
5.2 our Business Helpdesk at 6816 0088 for relocation, temporary suspension, termination, billing, lost or damaged hardware replacement matters.

6. Cancellation Charges are applicable for any withdrawal of application before the activation of Service. Cancellation Charges shall be 50% of the total contract value
unless otherwise stated.

7. A 30-days' notice is required for all Service terminations with Deactivation Charges apply unless otherwise stated. Early Termination Charges and deactivation charges
will apply if you terminate the services before service contract expiry date.

Customer's Installation Contact Details

Name of Contact Person: Contact Details of Contact Person

(For On-site Installation & Provisioning)
Office Number:

Mobile Number:

Email Address:

MyRepublic Service Application Form – Business Services E-48-03-140120 Page 2 of 3

 Specific Service Terms and Conditions

The applicable terms and conditions are:

Customer Acknowledgement

We hereby apply for the services set out in this form.

• I warrant I am an authorised officer authorised to enter into this contract on behalf of the business / company named in this Service
Application Form and have provided full and accurate information to MyRepublic.
• I/we acknowledge I/we have read all the applicable terms and conditions and policy documents and I/we accept to be bound by
them.
• I/we acknowledge and accept MyRepublic may use, store and discloseany information and data disclosed by me/use in accordance
to the MyRepublic Privacy Policy and understand I/we may withdraw such consent as prescibed by MyRepublic that maybe updated
from time to time.

___________________________________ ___________________________________ ____ /____ /________ ______________________________

Printed Name of Authorised Officer Signature of Authorised Officer Date (DD/MM/YYYY) Company Stamp

MyRepublic Service Application Form – Business Services E-48-03-140120 Page 3 of 3