Service Request Form

服务申请表格

Service Request Form

OM SPACE

Service Request Form

"*" indicates required fields

Type of Service Request*

Other

Customer Details

Full Name per IC / ID*

IC / ID No.*

Phone Number*

Email*

Company Name

Service Request Details

Reason of Service Request*

Transfer Between Courses

Transfer From

Transfer To

Transfer Between Sessions or Therapist

Transfer From

Transfer To

Transfer / Refund - Fee Calculation

Value of The Reserve Payment (in RM)

Previous Course / Service

Reserve Payment (in RM)

Change of Personal Information

Change of Personal Information - Name

Change of Personal Information - Phone Number

Change of Personal Information - Email

Change of Personal Information - Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Change of Personal Information - Other

Refund Details

Course / Session Name

Course / Session Value (in RM)

Refund - Course/Session Fee

Bank Name

Full Name / Payee

Bank Account Number

Refund Value (in RM)

Refund - Bank Charges

Bank Name

Full Name / Payee

Bank Account Number

Refund Value (in RM)

Refund of Bank Charges - Supporting Document

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 256 MB, Max. files: 5.

Refund - Deposit

Bank Name

Full Name / Payee

Bank Account Number

Refund Value (in RM)

Submission Date: 21/01/2022 / Submitted by

Comments

This field is for validation purposes and should be left unchanged.

服务申请表格