AYS

Name
	Gender: Male Female
Age:
I/C No.(new):
Date of Birth:
Address:
Postcode:
City / Town:
Contact No:	(Home)
	(Office)
Mobile No:
E-mail :
Current Profession:
Marital Status:	Single Married Divorced Widow Widower 9

1) How do you get to know about Sri Kulai Licensing Opportunity?

Newspaper TV News Magazine Friend

Others, please specify

2) How many Sri Kulai kiosk(s) are you intended to operate?

No. of Kiosk(s)

3) Your Budget?

4) Purchase Timeframe –
3 months, 6 months, 9 months, 12 months, 18 months

5) Do you have any specified location?

Yes No

If yes, pleased state the location

6) Any comment / suggestion on our Sri Kulai kiosk?