BSN MyRinggit/i APPLICATION FORM BORANG PERMOHONAN BSN MyRinggit/i

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1 BSN MyRinggit/i APPLICATION FORM BORANG PERMOHONAN BSN MyRinggit/i Islamic / Islamik Conventional / Konvensional Scheme / Skim : Individual / Individu Non-Individual / Bukan Individu Registered in Sabah / Sarawak : Branch Code Staff ID Together with this application, I wish to apply for / Bersama dengan permohonan ini, saya ingin memohon BSN Credit Card Kad Kredit BSN Cash Shield Perlindungan Tunai-i Will Writing Service Penulisan Surat Wasiat PLEASE WRITE IN CAPITAL LETTERS AND ( ) AS APPROPRIATE SILA TULIS MENGGUNAKAN HURUF BESAR DAN TANDAKAN ( ) PADA RUANG YANG BERKENAAN FINANCING DETAILS / MAKLUMAT PEMBIAYAAN Financing Amount / Amaun Pembiayaan RM Tenure (Months) / Tempoh (Bulan) Financing Type / Jenis Pembiayaan Financing Purpose / Tujuan Pembiayaan New Baharu Overlap Bertindih SSP Pledge Sandaran SSP BSN Giro/i Account No. No. Akaun BSN Giro/i A l APPLICANT DETAILS / MAKLUMAT PEMOHON PERSONAL / COMPANY DETAILS MAKLUMAT PERIBADI / SYARIKAT / No. Kad Pengenalan Gender Jantina Race Bangsa Male / Lelaki Female / Perempuan Malay Melayu Marital Status Status Perkahwinan Chinese Cina Single Bujang Bumiputera Indian India Married Berkahwin Yes / Ya No / Tidak No. of dependents Bil. Tanggungan Permanent Address / Alamat Tetap Residential Type / Jenis Kediaman Own / Sendiri Family / Quarters / Keluarga / Kuarters Rental / Sewa Mailing Address (if different from above) / Alamat Surat Menyurat (jika berbeza dari di atas) / Education Level / Tahap Pendidikan Certificate / Sijil Diploma / Diploma 0 Degree / Ijazah / EMPLOYMENT DETAILS / MAKLUMAT PEKERJAAN Occupation / Pekerjaan Commencement of Service (ddmmyyyy) Tarikh Mula Berkhidmat (hhbbtttt) Employer's Majikan Gross Monthly Income Pendapatan Kasar Bulanan RM Office Address / Alamat Pejabat Office Phone No. / No. Tel Pejabat Office Pejabat Office Fax No / No. Faks Pejabat Employment Status Status Pekerjaan Employed / Bekerja Self - employed / Bekerja Sendiri Unemployed / Tidak bekerja Permanent / Tetap Professional / Profesional With other income / Mempunyai sumber pendapatan lain Contract / Kontrak Non professional / Bukan Profesional Without any other income / Tiada sebarang sumber pendapatan

2 Company Type Jenis Syarikat Govt. ncies nsi Kerajaan Statutory Body Badan Berkanun Financial Institution Institusi Kewangan Govt. Linked Corporation Sykt. Berkaitan Kerajaan KLSE Listed Sykt. Awam Bhd Private Limited Sdn Bhd Business Type / Jenis Perniagaan Company Size / Saiz Syarikat Small (<15 employees) / Kecil (<15 orang pekerja) Medium (15-50 employees) / Sederhana (15-50 orang pekerja) Large (>50 employees) / Besar (>50 orang pekerja) Previous Employer's Majikan Terdahulu APPLICANT ADDITIONAL DETAILS / MAKLUMAT TAMBAHAN PEMOHON If you are introduced by BSN employee, please provide the name / Jika anda diperkenalkan oleh kakitangan BSN, sila berikan nama berkenaan If your children / spouses / parents / are an employee of BSN or any of BSN subsidiaries, please provide the name Jika anak / pasangan / ibu-bapa adalah pekerja BSN atau mana-mana anak syarikat BSN, sila nyatakan nama Existing Financing Information Update (*if BSN, please state financing acc. no.) Pengemaskinian Informasi Pembiayaan sedia ada (*jika BSN, sila nyatakan no. akaun pembiayaan) No. Bank Type of Financing Jenis Pembiayaan Financing Amount Jumlah Pembiayaan Applicant / Guarantor Pemohon / Penjamin Monthly Installment Ansuran Bulanan Current Balance Baki Pembiayaan Semasa End Date of Financing Tarikh Tamat Pembiayaan Existing BSN Financing Acc. No. / No. Akaun Pembiayaan BSN Sedia Ada Overlapped / pledge certificate details Maklumat sijil yang dicagarkan / disandarkan No. Bil. From / Dari Certificate No. / Nombor Sijil To / Hingga Amount / Bilangan (Unit) Account No. / No. Akaun (RM) SPOUSE DETAILS / MAKLUMAT PASANGAN Spouse's Pasangan No. Tel. Bimbit Office Phone No. No. Tel. Pejabat Occupation / Pekerjaan Commencement of Service (ddmmyyyy) Tarikh Mula Berkhidmat Gross Monthly Income Pendapatan Kasar Bulanan RM Employer's Majikan Office Address / Alamat Pejabat B l REFEREES DETAILS / MAKLUMAT PERUJUK (NOT LIVING WITH APPLICANT / TIDAK TINGGAL BERSAMA PEMOHON ) RELATIVE DETAILS / MAKLUMAT SAUDARA / Relationship With Applicant / Hubungan Dengan Pemohon

3 Occupation / Pekerjaan FRIEND DETAILS / MAKLUMAT RAKAN Mr / Encik Mrs / Puan Miss / Cik / Office Phone No. No. Tel. Pejabat C l JOINT APPLICANT OR GUARANTOR DETAILS / MAKLUMAT PEMOHON BERSAMA ATAU PENJAMIN (if required / jika diperlukan ) Joint Applicant / Pemohon Bersama Guarantor / Penjamin / Relationship With Applicant / Perhubungan Dengan Pemohon Gender Jantina Race Bangsa Male / Lelaki Female / Perempuan Malay Melayu Marital Status Status Perkahwinan Chinese Cina Single Bujang Bumiputera Indian India Married Berkahwin Yes / Ya No / Tidak No. of dependents Bil. Tanggungan Permanent Address / Alamat Tetap Residential Type / Jenis Kediaman Own / Sendiri Family / Quarters / Keluarga / Kuarters Rental / Sewa / Mailing Address (if different from above) / Alamat Surat Menyurat (jika berbeza dari atas) Education Level / Tahap Pendidikan Certificate / Sijil Diploma / Diploma Degree / Ijazah / Employment Status Status Pekerjaan Employed / Bekerja Self - employed / Bekerja Sendiri Unemployed / Tidak bekerja Permanent / Tetap Professional / Profesional With other income / Mempunyai sumber pendapatan lain Contract / Kontrak Non professional / Bukan Profesional Without any other income / Tiada sebarang sumber pendapatan D l BUNDLING PRODUCTS / PROMOSI PRODUK CREDIT CARD APPLICATION / PERMOHONAN KREDIT KAD I wish to apply for / saya ingin memohon : Islamic Credit Card / Kad Kredit Islamik Conventional Credit Card / Kad Kredit Konvensional Card Type / Jenis Kad : BSN Visa Platinum BSN Visa Gold BSN Visa Standard BSN MasterCard Platinum BSN MasterCard Gold BSN MasterCard Standard Co-Brand Cards / Kad Jenama Bersama: 1 TEACHERSCARD MasterCard Gold AIAFAM-BSN Visa Platinum Business Other BSN Credit Card UUM - BSN MasterCard Platinum UUM - BSN MasterCard Gold Name to appear on card / Nama di atas kad (Maximum 19 characters / Tidak melebihi 19 huruf) Mother's Full Name (for security verification) Nama Penuh Ibu (untuk pengesahan keselamatan) Please send my statement to / Sila hantar penyata saya ke Please send my card to / Sila hantar kad saya ke Home / Rumah Home / Rumah Office / Pejabat Office / Pejabat Collect at Branch / Pengambilan kad di Cawangan BSN CASH SHIELD / PERLINDUNGAN TUNAI-i BSN Cash Shield (for all conventional products except SPD SCOP and SPD ATM / untuk semua produk konvensional kecuali SPD SCOP dan SPD ATM) Perlindungan Tunai-i (for all Islamic products / untuk semua produk Islamik)

4 E l MONTHLY INCOME AND EXPENSES / PENDAPATAN DAN PERBELANJAAN BULANAN Monthly Income / Pendapatan Bulanan Basic Salary / Gaji Pokok Fixed Allowances / Elaun Tetap Income from Properties / Pendapatan dari Harta Income from Business / Pendapatan dari Perniagaan Other source of Income / Pendapatan Total Monthly Income / Jumlah Pendapatan Bulanan Monthly Expenses / Perbelanjaan Harian Cost of Living / Sara Hidup Loan Installments / Ansuran Pinjaman Income Tax / Cukai Pendapatan EPF / SOCSO Insurance / Takaful Insurans / Takaful / Total Monthly Expenses / Jumlah Perbelanjaan Bulanan Net Income / Pendapatan Bersih Applicant / Pemohon Joint Applicant / Guarantor Pemohon Bersama / Penjamin F l DECLARATION / DEKLARASI FOR ALL PRODUCTS I hereby declare that I have read and understand the terms and conditions of the product(s) applied herein and further declare that :- Saya mengesahkan bahawa saya telah membaca dan memahami syarat-syarat permohonan ini. Saya mengakui bahawa :- a. I have attained the age of majority and there is no legal action has been charged or taken against me. Saya telah cukup umur dan tiada sebarang tindakan mahkamah yang dikenakan ke atas saya. b. All information given by me are true and I have not withheld any material fact. Semua maklumat yang diberikan adalah benar dan saya tidak menyembunyikan sebarang maklumat. c. In the event this application is approved and the information given by me is found to be false, the Bank reserves its right to cancel the facility or impose any other condition on me. Bank berhak menarik balik fasiliti tersebut atau mengenakan sebarang syarat lain ke atas saya, jika maklumat yang diberikan tidak benar. d. I understand that the Bank reserves the absolute right to approve or decline this application as the Bank deems fit without assigning any reason. Saya faham bahawa pihak Bank mempunyai hak mutlak untuk meluluskan atau menolak permohonan ini tanpa menyatakan sebarang alasan. e. I hereby declare that: Saya dengan ini mengisytiharkan: I am connected to Bank Simpanan Nasional as follows : Saya mempunyai kaitan dengan Bank Simpanan Nasional seperti berikut: (a) To be completed by the individual applicant (if applicable). Untuk dilengkapkan oleh pemohon individu (jika berkenaan). I/we...have close relatives who is/are a staff of the Bank, particulars of which are as follows: Saya/kami... mempunyai saudara terdekat yang bertugas sebagai kakitangan di Bank, maklumat adalah seperti berikut: (b) To be completed by the applicant company / firm / partnership only (if applicable). Untuk dilengkapkan oleh syarikat / firma / perkongsian pemohon sahaja (jika berkenaan).... being director(s) / partner(s) / sole proprietor of the applicant company / partnership / firm do have close relatives who is / are a staff of the Bank, particulars of which are as follows :... sebagai pengarah / rakan kongsi / pemilik tunggal / perkongsian / firma mempunyai saudara terdekat yang bertugas sebagai kakitangan di Bank, maklumat adalah seperti berikut : Name of Connected Party Nama Pihak Berkaitan NRIC / Passport No. No KP / Pasport Nature of Relationship Jenis Perhubungan To the best of my knowledge, I am not connected to Bank Simpanan Nasional in any of the way listed below: Berdasarkan pengetahuan saya, saya tidak mempunyai kaitan dengan Bank Simpanan Nasional melalui apa-apa cara yang disenaraikan di bawah: (a) I am not related/ connected to any employee, director of BSN or any of its subsidiary. Saya tidak mempunyai sebarang pertalian dengan mana-mana kakitangan, pengarah atau anak syarikat BSN. (b) I am not a contractor, vendor, supplier OR have any commercial transactions, contract or outsourcing dealings with BSN or any of its subsidiaries. Saya bukan kontraktor, vendor, pembekal ATAU mempunyai apa-apa urus niaga komersial, kontrak atau urusan penyumberan luar dengan BSN atau anak syarikatnya. (c) None of my family member* (either personally or through their firm or company) is a contractors, vendors, suppliers or has any commercial transactions, contract or outsourcing dealings with BSN or any of its subsidiaries. Tiada ahli keluarga* saya (sama ada secara peribadi atau melalui firma atau syarikat) adalah kontraktor, vendor, pembekal ATAU mempunyai apa-apa urus niaga komersial, kontrak atau urusan penyumberan luar dengan BSN atau anak syarikatnya. * "family members" refers to spouse, parent, parent in-law, child (including adopted child and stepchild), spouse of his child, brother, sister, spouse of brother and sister or any dependents. * "ahli keluarga" merujuk kepada suami atau isteri, ibubapa, ibubapa mertua, anak (termasuk anak angkat dan anak tiri)serta menantu, adik-beradik lelaki dan perempuan serta ipar atau mana-mana tanggungan. f. I hereby consent and authorise the Bank to process my personal information and disclose any information in connection with this application(s) to any bureau, board or agency established by the Bank Negara Malaysia (BNM) such as the Central Credit Bureau (CCRIS), Dishonoured Cheques Information System (DCHEQS), RAM Credit Information (RAMCI), the Association of Banks in Malaysia or any other authorities, including but not limited to any subsidiary of the Bank and any related party which the Bank deem appropriate for the purposes of processing this application. Saya dengan ini memberi persetujuan dan kebenaran kepada pihak Bank untuk memproses maklumat peribadi saya dan menzahirkan apa-apa maklumat berkaitan permohonan ini kepada mana-mana biro, lembaga atau agensi yang ditubuhkan oleh Bank Negara Malaysia seperti Biro Kredit Pusat (CCRIS),Sistem Maklumat Cek Tidak Laku (DCHEQS), Maklumat Kredit (RAMCI), Persatuan Bank-bank Malaysia atau mana-mana pihak berkuasa lain, termasuk mana-mana anak syarikat Bank dan mana-mana pihak yang difikirkan wajar oleh pihak Bank untuk tujuan pemprosesan permohonan ini. g. Please choose one / Sila pilih salah satu I hereby CONSENT and AUTHORISE the Bank to disclose and share my information for the purpose of cross selling, marketing and promotional activities with any party, including but not limited to the Bank s subsidiaries, service providers or strategic business partners. Saya dengan ini BERSETUJU dan MEMBENARKAN pihak Bank menzahirkan dan berkongsi apa-apa maklumat saya yang relevan untuk tujuan jualan silang, pemasaran dan aktiviti promosi dengan mana-mana pihak termasuk tetapi tidak terhad kepada anak syarikat Bank, pembekal perkhidmatan, dan rakan kongsi perniagaan strategik. I hereby DO NOT CONSENT and DO NOT AUTHORISE the Bank to disclose and share my information for the purpose of cross selling, marketing and promotional activities with any party. Saya dengan ini TIDAK BERSETUJU dan TIDAK MEMBENARKAN pihak Bank menzahirkan dan berkongsi apa-apa maklumat saya yang relevan untuk tujuan jualan silang, pemasaran dan aktiviti promosi dengan mana-mana pihak.

5 h. I have read and agreed with the Bank Privacy Notice which can be obtained from the Saya telah membaca dan bersetuju dengan Notis Privasi Bank yang boleh diperolehi dari i. I hereby undertake that I will not use this facility to channel any proceeds from unlawful activities and I agree to provide the Bank with all information and documents, as and when required by the Bank, for the purpose of my identification or verification of the source of my fund to comply with the releva nt Anti- Money Laundering, Anti- Terrorism Financing and Proceeds of Unlawful Activities Act 2001 requirements. Saya dengan ini mengaku janji bahawa saya tidak akan menggunakan kemudahan ini untuk menyalurkan apa-apa hasil daripada aktiviti-aktiviti haram dan saya juga bersetuju untuk membekalkan semua maklumat dan dokumen-dokumen, sebagaimana dan apabila dikehendaki oleh Bank, untuk tujuan pengenalan diri saya atau pengesahan sumber dana bagi mematuhi keperluan Akta Pencegahan Pengubahan Wang Haram, Pencegahan Pembiayaan Keganasan dan Hasil daripada Aktiviti Haram j. If there are any changes to your personal information, BSN reserve the right to update your information in our system based on your feedback. We strive to ensure that our customer s information is accurate and updated. In order to ensure the records are accurate, we encourage you to inform u s if there are any changes to your information. Jika terdapat sebarang perubahan maklumat peribadi anda, pihak BSN berhak untuk mengemaskini maklumat tersebut di sistem kami berdasarkan maklumbalas anda. Kami sentiasa berusaha untuk memastikan maklumat pelanggan kami adalah tepat dan terkini. Demi memastikan ketepatan maklumat tersebut, adalah sangat penting untuk anda memaklumkan kepada kami jika terdapat sebarang perubahan maklumat. FOR CREDIT CARDS / UNTUK KAD KREDIT a. I agree to be bound by all the terms and conditions of the BSN Visa/MasterCard Agreement and all future amendments thereto.th is application shall form my agreement with BSN for the use of my BSN Visa/MasterCard Credit Card. Saya bersetuju kepada segala terma-terma dan syarat-syarat Perjanjian BSN Visa/MasterCard dan sebarang pindaan pada masa akan datang. Borang permohonan ini akan dianggap sebagai perjanjian saya dengan BSN bagi penggunaan Kad Kredit Visa/MasterCard BSN. b. The Principal Cardholder shall be liable to the Bank for all charges due and payable to the Bank arising from the use o f the Card or Supplementary Card provided. Pemegang Kad Utama (Principal Cardholder) hendaklah bertanggungjawab kepada Bank terhadap segala caj yang patut dan perlu dibayar kepada Bank yang timbul berhubung penggunaan Kad Utama atau Kad Tambahan (Supplementary Card) yang disediakan. FOR CASH SHIELD / PERLINDUNGAN TUNAI-i Declaration if agree to subscribe to BSN CASH SHIELD Cover / CASH-i cover: Pengakuan sekiranya bersetuju mengambil PERLINDUNGAN BSN CASH SHIELD / PERLINDUNGAN TUNAI-i : a. I hereby understand and agree that the cost of BSN Cash Shield cover / Cash-i cover is only RM318 (cost inclusive of GST) of a single payment for 3 years protection. This coverage is provided by AIG Malaysia Insurance Berhad ( W) / Syarikat Takaful Malaysia Berhad ( K) with BSN cooperation. I hereby understand and agree that contributions and other charges are subject to goods and services tax ("GST") in accordance with the Goods and Services Tax Act 2014 ("GST Act") and I undertake to pay the GST fee that is levied in addition to the contribution and other charges (if applicable). I also declared that I have carefully read and understood the details of the Product Disclosure Sheet of BSN Cash Shield / Cash-i cover which can be found on the website / Saya memahami dan bersetuju bahawa kos Perlindungan BSN Cash Shield / Perlindungan Tunai-i adalah dengan hanya RM318 (harga termasuk GST) sekali pembayaran untuk 3 tahun perlindungan. Perlindungan ini disediakan oleh AIG Malaysia Insurance Berhad ( W) / Syarikat Takaful Malaysia Berhad ( K) di atas kerjasama BSN. Saya faham dan bersetuju bahawa sumbangan dan lain-lain caj yang dikenakan adalah tertakluk kepada cukai barangan dan perkhidmatan ("GST") selaras dengan Akta Cukai Barangan dan Perkhidmatan 2014 ("Akta GST") dan saya bertanggungjawab untuk membayar jumlah bayaran GST yang dikenakan sebagai tambahan ke atas sumbangan dan caj-caj lain (jika berkenaan). Saya juga mengaku bahawa saya telah membaca dengan teliti dan memahami butiran Penyata Pendedahan Produk untuk BSN Cash Shield / Perlindungan Tunai-i dan ianya boleh didapati di laman web / I hereby declare and agree that: Saya dengan ini mengisytiharkan dan bersetuju bahawa: i. I hereby certify that all written information provided by me for this product or any questionnaires or other related documents that were signed by me in relation with the application and the reply given to the Bank is full, complete, truthful and accurate. I undertake that the Bank will rely and act on such given information, failure of which, any policy issued or coverage granted by the Bank will be invalid and can be withdrawn at the discretion of the Bank. Semua maklumat bertulis yang disediakan oleh saya untuk produk ini atau soal selidik rasmi atau lain-lain dokumen yang ditandatangani oleh saya berhubung dengan permohonan dan jawapan yang diberi kepada Bank adalah penuh, lengkap, benar dan betul. Saya faham bahawa pihak Bank meyakinkan kebenaran maklumat yang diberi akan bergantung dan bertindak berdasarkan maklumat tersebut, jika tidak mana-mana polisi yang dikeluarkan atau perlindungan yang diberi oleh pihak Bank adalah tidak sah dan boleh dibatalkan atas budi bicara pihak Bank. ii. I undertake that it is my responsibility to provide complete, truthful and accurate information for the foregoing que stions in the application form. I will notify the Bank if there are any changes to my risk profile. Failing which, the Bank has right to either continue or add additional terms and conditions or terminate the coverage. I understand that failure to inform the Bank about any changes to my risk profile may affect my rights in making a claim. Saya faham bahawa menjadi tanggungjawab saya untuk memberikan maklumat yang lengkap, benar, dan tepat semasa menjawab soalan -soalan di dalam borang permohonan. Saya akan memaklumkan pihak Bank tentang sebarang perubahan ke atas profil risiko saya. Pihak Bank berhak untuk meneruskan perlin dungan, menambah terma dan syarat atau menamatkan perlindungan sekiranya saya gagal untuk berbuat demikian. Saya memahami bahawa kegagalan memaklumkan pihak Bank tentang sebarang per ubahan profil risiko saya mungkin akan mempengaruhi hak saya semasa membuat tuntutan. iii. Any personal information collected or held by the Bank (whether contained in this application or otherwise obtained) is provided to the Bank and may be held, used and disclosed by the Bank to individual, agency or organization that provide services, organization associated with the Bank for the purpose of processing this application and providing subsequent services for Bank financial products and services and data matching, and to communicate with me for such purposes. I understand that I have the right to access and to request for correction of any personal information held by the Bank in relation to me. Such request may be made in writing to the Bank at Wisma BSN, 117 Jalan Ampang, Kuala Lumpur or at telephone number: or via fax: or e-mai:l customercare@bsn.com.my Mana-mana maklumat peribadi yang dikumpulkan atau dipegang oleh pihak Bank (sama ada terkandung dalam permohonan ini atau dipero lehi dengan cara lain) diberikan kepada pihak Bank dan boleh dipegang, diguna dan dikemukakan oleh pihak Bank kepada individu, badan atau organisasi yang menyediakan perkhidmatan, organisasi yang berkaitan dengan pihak Bank bagi tujuan memproses permohonan ini dan memberikan perkhidmatan seterusnya untuk produk dan perkhidmatan kewangan Bank dan pemadan an data, soal selidik dan untuk berkomunikasi dengan saya untuk tujuan seperti itu. Saya faham bahawa saya berhak memperoleh akses kepada, dan memohon pembetulan kepada apa -apa maklumat peribadi yang dipegang oleh pihak Bank berkaitan dengan saya. Permohonan seperti itu boleh dibuat secara bertulis kepada pihak Bank di Wisma BSN, 117 Jalan Ampang, Kuala Lumpur atau di talian: atau menerusi faksimili: atau e-mel: customercare@bsn.com.my iv. By submitting my personal information, I agree to authorize the Bank to communicate with me about the latest products, services and new functions of the Bank. If I do not wish to be contacted by the Bank, I can opt out at any time by writing to the Bank as mentioned above. Dengan menyerahkan maklumat peribadi saya, saya bersetuju untuk membenarkan pihak Bank berkomunikasi dengan saya berkenaan pr oduk terbaharu, perkhidmatan dan acara-acara baharu pihak Bank. Jika saya tidak mahu dihubungi oleh pihak Bank, saya boleh memilih keluar bila-bila masa dengan menulis kepada pihak Bank seperti di atas. Applicant's Signature Tandatangan Pemohon Guarantor's Signature Tandatangan Penjamin G l FOR BANK USE ONLY/ UNTUK KEGUNAAN BANK SAHAJA To be filled by BSN representative I hereby declare that the followings are true and correct to the best of my knowledge :- 1. I have sighted the Identity Card for both the applicant and guarantor. 2. I have verified that the information furnished by the customer is true and correct to the best of my knowledge. 3. I confirmed that the financing application form was signed by the customer. Staff's Signature and Stamp / Tandatangan dan Cop Staf

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