Face Book "Like" Us Contest Sign Up Form

For those who are interested to join our FaceBook "Like" Us Contest, please fill the registration form below to join this contest.

Name* :
D.O.Birth* :	- - Eg: Date - Month - Year
Your Location* :	Bercham Bandar Seri Botani Greentown Gunung Rapat Jelapang Menglembu Ipoh Old Town Ipoh Town Ipoh Garden East Ipoh Garden South Pasir Puteh Simpang Pulai Station 18 Tambun Pengkalan Pusing Chemor Kampar Kuala Kangsar Tasek Pasir Pinji
Occupation* :
H/P Number* :	- which the User ID & Password will SMS to you directly.
Email* :
Face Book Address* :	exp: www.facebook.com/garychung
All fields marked with "*" are compulsary.
	I have read, understand and accept the terms & conditions as stated in the web site.*
Note : If you found any error to send out this form, you can send (Pls email the details to : dgvmedia@gmail.com ) below information via your personal email system. Email should include the details of below : Name | DOB | Location | Occupation | H/P Handphone | Email | Face Book Address | to us. We will proceed your request a.s.a.p. Thank you!