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Hidden Fields
UTM_Source
UTM_Medium
UTM_Campaign
UTM_Content
Lead Source
PART 1: BASIC INFORMATION
NAME (AS PER MYKAD/PASSPORT)
MOBILE
Please select...
010
011
012
013
014
015
016
017
018
019
NUMBER
EMAIL ADDRESS
PART 2: BUSINESS INFORMATION
ARE YOU A BUSINESS OWNER?
Please select...
Yes
No
NATURE OF BUSINESS
Please select...
Café
Bakery
NAME OF CAF
É / BAKERY
COMPANY REGISTRATION NUMBER
TYPE OF MILK USED
UHT
PASTEURISED
WHAT DO YOU USUALLY USE THE MILK FOR?
Baking / Cooking / Dessert
Coffee
QUANTITY OF MILK USED PER MONTH (CARTON)
1 carton is 12 Litres of milk
ADDRESS LINE 1
ADDRESS LINE 2
POST CODE
CITY
STATE
Please select...
Johor Darul Takzim
Kedah Darul Aman
Kelantan Darul Naim
Melaka
Negeri Sembilan Darul Khusus
Pahang Darul Makmur
Perak Darul Ridzuan
Perlis Indera Kayangan
Pulau Pinang
Sabah
Sarawak
Selangor Darul Ehsan
Terengganu Darul Iman
Wilayah Persekutuan Kuala Lumpur
Wilayah Persekutuan Labuan
Wilayah Persekutuan Putrajaya
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