Mercedes-Benz Malaysia

Registration Form

Registration form

Please complete the form below.

Note that fields marked * are mandatory for us to process your request.

Title : *

(eg: Mr,Mrs,Tan Sri, Dato, etc..)

First Name : *

Last Name : *

Address : *

Postal Code : *

(eg: 50450)

Town / City :

State :

Country :

Gender : *
Male
Female

Email : *

Telephone (Off) :

(eg:6XX-XXXXXXXX)

Telephone (Hse) :

(eg:6XX-XXXXXXXX)

Mobile : *

(eg:6XXX-XXXXXXX)

Preferred Contact *
HouseOffice
Mobile

Car Model :

VIN/Chassis No *

Vehicle Registration No

Date of Registration *

Which dealer did you visit to purchase your vehicle?

Do you own other Mercedes-Benz vehicle? *
YesNo

If yes, which model?

Do you service & repair your vehicle at MB authorised service centres? *
YesNo

If yes, which service centre do you visit?