On-Line Web Hosting Service Application Form

To Apply for our hosting services, kindly fill in the form below and
click the Submit Button when you are done.

(* Required Fields)

Application Contact Details:

Full Name *
(as per Identity Card)
Identity Card No.
(for individuals only)
Company Name
(for Corporate Clients)
Company Reg. No.
(for Malaysian Companies)
E-mail Address *
Mobile Number
Telephone Number *
Fax Number

Billing / Mailing Address:

Street Address *
City / State *
Postcode / Zipcode *
Country *

Service Application Details:

Hosting Packages *

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Preferred Web Server Operating System *
Windows Linux

Domain Name to tag to this account
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www.. *


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Please key in details or comments (if any)

I confirm that all information given above is true and complete. I hereby authorise XGEN Technologies Sdn. Bhd. to verify the information from whatever sources and by whatever means that XGEN Technologies Sdn. Bhd. may consider appropriate. I confirm that I shall be subjected to the rules and regulations governing the use of the applied service(s). I understand that XGEN Technologies Sdn. Bhd. reserves the right to reject any application without any due reason or terminate any existing account if the information provided herein is incorrect.

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