Title

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Name*

Address

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City*

State*JohorKedahKelantanKuala LumpurMelakaNegeri SembilanPahangPenangPerakPerlisSabahSarawakSelangorTerengganuWilayah Persekutuan Kuala LumpurWilayah Persekutuan LabuanWilayah Persekutuan Putrajaya

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Phone contact no.*

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Which model are you interested in?B-ClassE-ClassOthersC-ClassS-Class

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Preferred test drive date

Preferred dealer/location*CentralCycle & Carriage Bintang Bhd, AmpangCycle & Carriage Bintang Bhd, Mutiara DamansaraCycle & Carriage Bintang Bhd, Petaling JayaHap Seng Star Sdn Bhd, Jln Sultan IsmailHap Seng Star Sdn Bhd, Balakong, SelangorHap Seng Star Sdn Bhd, Jalan Ipoh, KLNZ Wheels Sdn Bhd, KlangEastMofaz Exotic Car Sdn Bhd, Kuala TerengganuMofaz Exotic Car Sdn Bhd, Kota BahruNZ Wheels Sdn Bhd, KuantanNorthAsbenz Motors Sdn Bhd, Sg PetaniIpoh Motors Sdn Bhd, IpohLowe Motors Sdn Bhd, PenangMofaz Exotic Car Sdn Bhd, LangkawiSouthBR Jaya Sdn Bhd, Batu PahatCycle & Carriage Bintang Bhd, Johor BahruMBSA Automotive Malaysia Sdn Bhd, MelakaMinsoon Credit Corp (M) Sdn Bhd, SerembanNZ Wheels Sdn Bhd, Johor BahruEast MalaysiaN.A. Classic Sdn Bhd, LabuanHap Seng Star Sdn Bhd, Kota KinabaluHap Seng Star Sdn Bhd, Kuching

Data storage and data usage*I hereby grant my consent for the data gathered in relation to this contact to be processed and used by Mercedes-Benz Malaysia Sdn Bhd, the responsible distribution company and the local dealers within the Mercedes-Benz Malaysia sales organization for the purposes of advising and informing me about products, services and similar activities of the Daimler Group by mail, telephone and e-mail.