{"id":821,"date":"2020-08-22T18:54:53","date_gmt":"2020-08-22T10:54:53","guid":{"rendered":"https:\/\/myezy.com.my\/2019\/?page_id=821"},"modified":"2024-07-25T15:04:52","modified_gmt":"2024-07-25T07:04:52","slug":"order-form","status":"publish","type":"page","link":"https:\/\/myezy.com.my\/2019\/order-form\/","title":{"rendered":"Renewal Form"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_2' ><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/2019\/wp-json\/wp\/v2\/pages\/821'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>Renew Road Tax - Orang Awam<\/h3>\n                            <span class='gform_description'>General form for car insurance & road tax renewal\r\n\r\nKlien\/Customer -> My Ezy Services<\/span>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_16'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_16' >Submission No<\/label><\/li><li id='field_2_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_2' >NO HANDPHONE<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_2_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_3' >Alamat Emel<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_2_3' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_2_1'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_1' >Nama Penuh<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_1\"   aria-required=\"true\" aria-invalid=\"false\" \/><\/div><div class='gfield_description' id='gfield_description_2_1'>(Mengikut Kad Pengenalan)<\/div><\/li><li id='field_2_8'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_8' >No Kad Pengenalan<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'    placeholder='999999-99-9999' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_9'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_9' >Alamat Penuh<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_2_9' class='textarea small'    placeholder='Alamat penuh untuk penghantaran Slip\/Sticker Cukai Jalan' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_2_11'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_11' >No. Pendaftaran Kereta<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_12'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_12' >Model Kenderaan<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_21'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_21' >CC Kenderaan<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_31'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Syarikat Takaful \/ Insurans Pilihan Anda<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_31'><li class='gchoice_select_all'>\n\t\t\t\t\t\t<input type='checkbox' id='choice_31_select_all'   onclick='gformToggleCheckboxes( this )' onkeypress='gformToggleCheckboxes( this )' \/>\n\t\t\t\t\t\t<label for='choice_31_select_all' id='label_31_select_all' data-label-select='Select All' data-label-deselect='Deselect All'>Select All<\/label>\n\t\t\t\t\t<\/li><li class='gchoice_2_31_1'>\n\t\t\t\t\t\t\t\t<input name='input_31.1' type='checkbox'  value='Etiqa Takaful'  id='choice_2_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_1' id='label_2_31_1'>Etiqa Takaful<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_31_2'>\n\t\t\t\t\t\t\t\t<input name='input_31.2' type='checkbox'  value='Takaful Ikhlas'  id='choice_2_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_2' id='label_2_31_2'>Takaful Ikhlas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_31_3'>\n\t\t\t\t\t\t\t\t<input name='input_31.3' type='checkbox'  value='Takaful Malaysia'  id='choice_2_31_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_3' id='label_2_31_3'>Takaful Malaysia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_31_4'>\n\t\t\t\t\t\t\t\t<input name='input_31.4' type='checkbox'  value='Zurich Takaful'  id='choice_2_31_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_4' id='label_2_31_4'>Zurich Takaful<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_31_5'>\n\t\t\t\t\t\t\t\t<input name='input_31.5' type='checkbox'  value='Allianz Insurance'  id='choice_2_31_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_5' id='label_2_31_5'>Allianz Insurance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_31_6'>\n\t\t\t\t\t\t\t\t<input name='input_31.6' type='checkbox'  value='Liberty Insurance'  id='choice_2_31_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_6' id='label_2_31_6'>Liberty Insurance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_31_7'>\n\t\t\t\t\t\t\t\t<input name='input_31.7' type='checkbox'  value='AmGeneral @ Kurnia Insurance'  id='choice_2_31_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_31_7' id='label_2_31_7'>AmGeneral @ Kurnia Insurance<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_31'>Pilihan di tangan anda <\/div><\/li><li id='field_2_30'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Perlindungan Tambahan<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_30'><li class='gchoice_2_30_1'>\n\t\t\t\t\t\t\t\t<input name='input_30.1' type='checkbox'  value='Free Unlimited KM Towing'  id='choice_2_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1'>Free Unlimited KM Towing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_30_2'>\n\t\t\t\t\t\t\t\t<input name='input_30.2' type='checkbox'  value='Windscreen'  id='choice_2_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2'>Windscreen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_30_3'>\n\t\t\t\t\t\t\t\t<input name='input_30.3' type='checkbox'  value='E-Hailing'  id='choice_2_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3'>E-Hailing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_2_30_4'>\n\t\t\t\t\t\t\t\t<input name='input_30.4' type='checkbox'  value='Flood'  id='choice_2_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_4' id='label_2_30_4'>Flood<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_30'>Perlindungan Tambahan<\/div><\/li><li id='field_2_20'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_20' >Penghantaran<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_2_20' class='medium gfield_select'   aria-required=\"true\" aria-invalid=\"false\"><option value='Own Collection' selected='selected'>Own Collection<\/option><option value='Courier \/ Pos Laju' >Courier \/ Pos Laju<\/option><option value='Runner' >Runner<\/option><\/select><\/div><\/li><li id='field_2_15'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_15' >Nota \/ Pertanyaan?<\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_2_15-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css' href='https:\/\/myezy.com.my\/2019\/wp-includes\/css\/dashicons.min.css?ver=6.4.2' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css' href='https:\/\/myezy.com.my\/2019\/wp-includes\/css\/editor.min.css?ver=6.4.2' type='text\/css' media='all' \/>\n<div id=\"wp-input_2_15-editor-container\" class=\"wp-editor-container\"><textarea class=\"small wp-editor-area\" style=\"height: 110px\" autocomplete=\"off\" cols=\"40\" name=\"input_15\" id=\"input_2_15\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/li><li id='field_2_32'  class='gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_32' >Comments<\/label><div class='ginput_container'><input name='input_32' id='input_2_32' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description__32'>This field is for validation purposes and should be left unchanged.<\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' 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value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type='text\/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 2) {if(typeof Placeholders != 'undefined'){\n                        Placeholders.enable();\n                    }} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){} );<\/script><script type='text\/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [2, 1]) } ); 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