Perodua Smart Assist

Registration / Renewal Form.
Application Type
  • New
  • Renewal

Personal Details
Full NameAs in NRIC / Passport
  • Mr
  • Mrs
  • Miss
  • Others
NRIC NumberNew IC no. e.g. 561210-10-2301
  • -
  • -
Race
Marital Status
Mailing Address
  • Address line 1
  • Address line 2
  • Address line 3
  • Postcode
  • Area
  • State
Contact noPlease fill in at least one contact info.
  • Home Telephone No. / No. Telefon Rumah
    -
  • Office Telephone No. / No. Telefon Pejabat
    -
  • Mobile Telephone No. / No. Telefon Bimbit
    -
E-mail Address

Vehicle's Details
Vehicle Model
Vehicle Registration No.No spacing e.g. WQX1234
By submitting this form, I hereby acknowledge the rules and regulations laid in PSA's constitution and agrees to abide them.
The charges for renewal is RM15.00 (valid for one year).
After verification by the PSA team, we will advise on the payment method via email or telephone
Note:
- Please allow 5 working day for processing.
- Successfull application will be notified via Mail.