AFFINBANK WORLD MASTERCARD APPLICATION FORM BORANG PERMOHONAN KAD AFFINBANK WORLD MASTERCARD
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- Lionel Jefferson
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1 a. AFFINBANK WORLD MASTERCARD APPLICATION FORM BORANG PERMOHONAN KAD AFFINBANK WORLD MASTERCARD Age Eligibility: 21 years old and above for Principal Cardmember and 18 years old and above for Supplementary Cardmember / Kelayakan Umur: Berumur 21 tahun ke atas untuk Ahli Kad Utama dan 18 tahun ke atas untuk Ahli Kad Tambahan. Minimum Annual Income: / Pendapatan tahunan minimum : Card type / Jenis Kad Minimum Annual Income / Pendapatan Tahunan Minimum PLEDGE OF FIXED DEPOSIT / CAGARAN DEPOSIT TETAP Title / Gelaran : Mr. / Encik Mdm. / Puan Miss / Cik Others / Lain-lain : Full Name (As per IC / Passport) / Nama Penuh (Seperti dalam KP / Pasport) : AFFINBANK World Mastercard RM120,000 Fixed Deposit (FD) will be required as collateral for (i) a non-malaysian applicant and / or (ii) any applicants who are unable to provide any income evidence or supporting documents. The Fixed Deposit (FD) must be maintained with Affin Bank Berhad ("AFFINBANK") for as long as the credit card facility is available. / Deposit Tetap (FD) akan diperlukan sebagai cagaran untuk (i) pemohon bukan rakyat Malaysia dan / atau (ii) mana-mana pemohon yang tidak dapat memberi apa-apa bukti atau dokumen-dokumen sokongan pendapatan. Deposit Tetap (FD) hendaklah kekal di Affin Bank Berhad ("AFFINBANK") selagi kemudahan kad kredit masih wujud. Please complete all sections of the form in BLOCK LETTERS and tick ( ) boxes where appropriate. / Sila lengkapkan semua bahagian borang menggunakan HURUF BESAR dan tandakan ( ) di kotak yang sesuai. PRINCIPAL CARDMEMBER PERSONAL DETAILS / MAKLUMAT PERIBADI AHLI KAD UTAMA Name to appear on card. The name should be as per applicant s IC (maximum 19 characters) / Nama yang akan dicetak di kad. Nama ini hendaklah seperti KP pemohon (maksimum 19 huruf): New IC No. (Mandatory for Malaysian) / Old IC No. / Passport No. / No. KP Baru (Mandatori untuk Rakyat Malaysia): No. KP Lama / No. Pasport: - - Others ID No. / Lain-lain No. KP : Gender / Jantina : Male / Lelaki Date of Birth (DD / MM / YYYY) / Tarikh Lahir (HH / BB / TTTT) : Nationality / Kewarganegaraan : Race / Bangsa : / / Female / Perempuan Resident / Pemastautin : Non-Resident / Bukan Pemastautin : Referred as follows / Merujuk kepada yang berikut : Referred as follows / Merujuk kepada yang berikut : a. Malaysian citizen; / Rakyat Malaysia; a. Non-Malaysian citizen / Bukan rakyat Malaysia; Malaysian citizen with permanent resident status outside Malaysia who resides in Malaysia; or / Rakyat Malaysia dengan status pemastautin tetap di luar Malaysia yang menetap di Malaysia; atau c. Non-Malaysian citizen with permanent resident status in Malaysia c. who resides in Malaysia. / Bukan rakyat Malaysia dengan status pemastautin tetap di Malaysia yang menetap di Malaysia. (Note: Non-Malaysian citizen with Malaysia residential address is required to provide supporting document for verification on the resident status. / Nota: Bukan rakyat Malaysia dengan alamat kediaman Malaysia dikehendaki memberi dokumen sokongan untuk pengesahan status pemastautin). Mother's Name / Nama Ibu (Required for security verification purpose / Ciri keselamatan bagi tujuan pengesahan ): Non-Malaysian citizen with permanent resident status in Malaysia who resides outside Malaysia ; or / Bukan rakyat Malaysia dengan status pemastautin tetap di Malaysia yang menetap di luar Malaysia; atau Malaysian citizen with permanent resident status outside Malaysia who resides outside Malaysia. / Rakyat Malaysia dengan status pemastautin tetap di luar Malaysia yang menetap di luar Malaysia. (Note: Malaysian citizen with overseas residential address is required to provide supporting document for verification on the non-resident status. / Nota: Rakyat Malaysia dengan alamat kediaman luar negara dikehendaki memberi dokumen sokongan untuk pengesahan status bukan pemastautin). No. of Dependents / Bilangan Tangungan : Highest Education Level / Tahap Pendidikan Tertinggi : Primary / Rendah Secondary / Menengah Others / Lain-lain : College / Kolej University / Universiti Marital Status / Status Perkahwinan : Single / Bujang Married / Berkahwin Divorced / Bercerai Widow / Balu Page 1 of 8
2 Spouse s Name (As in IC / Passport) / Nama Penuh Suami / Isteri (Seperti dalam KP / Pasport) : VERSION-3/JAN/2018/WC/APPS Spouse's Company Full Name / Nama Penuh Syarikat Suami / Isteri : Spouse s Office Telephone No. / No. Telefon Pejabat Suami / Isteri : - Extension / Sambungan: Handphone No. / No. Telefon Bimbit : RESIDENTIAL DETAILS / MAKLUMAT KEDIAMAN Residential Address (Please do not provide P.O. Box address) / Alamat Kediaman (Sila jangan berikan alamat Peti Surat) : Residential Telephone No. / No. Telefon Kediaman : Handphone No. / No. Telefon Bimbit : - / E-mel : Type of Residential / Jenis Kediaman : Owned Property / Milik Sendiri Mortgage / Gadai Janji Others / Lain-lain : Renting / Menyewa Parents / Relatives / Ibu Bapa / Saudara Years of Stays / Tempoh Menetap : / (YY / TT ) / (MM / BB ) Permanent Residential Address (If different from Residential Address) / Alamat Kediaman Tetap (Jika lain dari Alamat Kediaman) : Telephone No. / No. Telefon : - EMPLOYMENT DETAILS / MAKLUMAT PEKERJAAN Salaried / Bergaji Self Employed / Bekerja Sendiri Unemployed / Tidak Berkerja Name of Company / Nama Syarikat : Nature of Business / Jenis Perniagaan : Office Address (Please do not provide P.O. Box address) / Alamat Pejabat (Sila jangan berikan alamat Peti Surat) : Position / Jawatan : Office Telephone No. / No. Telefon Pejabat : - Extension / Sambungan: Length of Service / Tempoh Berkhidmat : / (YY / TT ) / (MM / BB ) Previous Employment Information / Maklumat Majikan Sebelumnya Name of Previous Company / Nama Syarikat Sebelumnya : Nature of Business / Jenis Perniagaan : Position / Jawatan : Length of Service / Tempoh Berkhidmat : / (YY / TT ) / (MM / BB ) Annual Income / Pendapatan Tahunan Annual Gross Income (RM) / Pendapatan Kasar Tahunan (RM) : Other annual income, if any (RM) / Lain-lain pendapatan tahunan jika ada (RM) : Please enclose supporting document(s) / Sila lampirkan dokumen-dokumen sokongan Page 2 of 8
3 OTHER CREDIT / CHARGE CARDS OWNED / LAIN-LAIN KAD KREDIT / CAJ YANG DIMILIKI Name of Issuer / Nama Pengeluar Member since / Ahli semenjak Credit limit / Had Kredit NON-BANK OBLIGATION / TANGGUNGAN DENGAN INSTITUSI BUKAN BANK Declaration on monthly non-bank obligation (excluding deductions appearing on payslip), If no obligation, kindly cross out the below table / Pengisytiharan tanggungan bulanan dengan institusi bukan Bank (tidak termasuk potongan melalui gaji), Jika tiada tanggungan, sila pangkah jadual di bawah : No. Company / Syarikat Type / Jenis Monthly Payment (RM) / Bayaran Bulanan (RM) MAILING ADDRESS / ALAMAT SURAT - MENYURAT To residence address / Ke alamat kediaman To office address / Ke alamat pejabat PRINCIPAL S PERSONAL REFERENCE / RUJUKAN PERIBADI AHLI KAD UTAMA Name of Relative / Friend who does not reside together / Nama Saudara / Rakan yang tidak tinggal bersama : Relationship with Principal Cardmember / Hubungan dengan Ahli Kad Utama : Residential Telephone No / No. Telefon Kediaman : Handphone No. / No. Telefon Bimbit : Office Telephone No. / No. Telefon Pejabat : - Extension / Sambungan: SUPPLEMENTARY CARDMEMBER PERSONAL DETAILS / MAKLUMAT PERIBADI AHLI KAD TAMBAHAN Title / Gelaran : Mr. / Encik Mdm. / Puan Miss / Cik Others / Lain-lain : Full Name (As per IC / Passport) / Nama Penuh (Seperti dalam KP / Pasport) : Name to appear on card. The name should be as per applicant s IC (maximum 19 characters) / Nama yang akan dicetak di kad. Nama ini hendaklah seperti KP pemohon (maksimum 19 huruf): New IC No. (Mandatory for Malaysian) / Old IC No. / Passport No. / No. KP Baru (Mandatori untuk Rakyat Malaysia): No. KP Lama / No. Pasport: - - Others ID No. / Lain-lain No. KP : Gender / Jantina : Male / Lelaki Date of Birth (DD / MM / YYYY) / Tarikh Lahir (HH / BB / TTTT) : Nationality / Kewarganegaraan : Race / Bangsa: / / Female / Perempuan Resident / Pemastautin : Non-Resident / Bukan Pemastautin : Referred as follows / Merujuk kepada yang berikut : Referred as follows / Merujuk kepada yang berikut : a. Malaysian citizen; / Rakyat Malaysia; a. Non-Malaysian citizen / Bukan rakyat Malaysia; Malaysian citizen with permanent resident status outside Malaysia Non-Malaysian citizen with permanent resident status in Malaysia who who resides in Malaysia; or / Rakyat Malaysia dengan status resides outside Malaysia; or / Bukan rakyat Malaysia dengan status pemastautin tetap di luar Malaysia yang menetap di Malaysia; pemastautin tetap di Malaysia yang menetap di luar Malaysia; atau atau c. Non-Malaysian citizen with permanent resident status in Malaysia c. who resides in Malaysia. / Bukan rakyat Malaysia dengan status pemastautin tetap di Malaysia yang menetap di Malaysia. Malaysian citizen with permanent resident status outside Malaysia who resides outside Malaysia. / Rakyat Malaysia dengan status pemastautin tetap di luar Malaysia yang menetap di luar Malaysia. (Note: Non-Malaysian citizen with Malaysia residential address is required to provide supporting document for verification on the resident status. / Nota: Bukan rakyat Malaysia dengan alamat kediaman Malaysia dikehendaki memberi dokumen sokongan untuk pengesahan status pemastautin). (Note: Malaysian citizen with overseas residential address is required to provide supporting document for verification on the non-resident status. / Nota: Rakyat Malaysia dengan alamat kediaman luar negara dikehendaki memberi dokumen sokongan untuk pengesahan status bukan pemastautin). Page 3 of 8
4 Mother's Name / Nama Ibu (Required for security verification purpose / Ciri keselamatan bagi tujuan pengesahan ): VERSION-3/JAN/2018/WC/APPS Relationship with Principal Cardmember / Hubungan dengan Ahli Kad Utama : Residential Address (Please do not provide P.O. Box address) / Alamat Kediaman (Sila jangan berikan alamat Peti Surat) : Residential Telephone No. / No. Telefon Kediaman : Handphone No. / No. Telefon Bimbit : - / E-mel : Name of Company (if any) / Nama Syarikat (jika ada) : Office's Address (if any) / Alamat pejabat (jika ada) : Nature of Business / Jenis Perniagaan : Position / Jawatan : Office Telephone No. / No. Telefon Pejabat : - Extension / Sambungan: Please tick one ( ) / Sila tandakan ( ) salah satu : Sharing Principal's credit limit / Berkongsi had kredit Ahli Kad Utama Assign credit limit / Had kredit ditetapkan :RM Note: a. Sharing / assigned credit limit must not exceed the Principal Cardmember's approved credit limit. All transactions and charges for Supplementary Card will be included in the Principal Cardmember's credit card statement. c Payment must be made separately for each Supplementary Card with assigned credit limit. Nota: a. Had limit berkongsi/ditetapkan hendaklah tidak melebihi had kredit Ahli Kad Utama yang diluluskan. Semua transaksi dan caj untuk Kad Tambahan akan dimasukkan ke dalam penyata kad kredit Ahli Kad Utama. c. Bayaran berasingan hendaklah dibuat untuk setiap Kad Tambahan dengan had kredit ditetapkan. DECLARATION / PERAKUAN I / We confirm: a. That all personal data that I/we have provided are all true, up-to-date and accurate. Should there be any changes to any of my / our personal data, I / we shall notify AFFINBANK immediately. I / We hereby authorise AFFINBANK to verify the information with the Inland Revenue Board and/or whatever sources by any means that AFFINBANK considers appropriate. Saya / Kami mengesahkan: a. Bahawa semua maklumat peribadi yang saya / kami berikan adalah semuanya benar, yang terkini dan betul. Sekiranya terdapat perubahan terhadap mana-mana maklumat peribadi saya / kami, saya/kami akan memberi notis dengan segera kepada AFFINBANK. Saya / Kami dengan ini memberikan kuasa kepada AFFINBANK untuk mengesahkan kenyataan ini daripada Lembaga Hasil Dalam Negeri dan/atau mana-mana sumber yang AFFINBANK fikirkan sesuai. That the transactions to be effected using the credit card account and monies of funds to be used for repayment of the credit card account are neither obtained from any unlawful source nor related to any unlawful activities as defined under the Anti-Money Laundering, Anti-Terrorism Financing and Proceeds of Unlawful Activities Act 2001 (AMLA). I / We acknowledge that it is a requirement by Bank Negara Malaysia (BNM) that all information relating to this application, whether successful or otherwise, must be updated and / or transmitted to the Central Credit Reference Information System (CCRIS) database maintained by BNM. I / We agree that my/our signing of the AFFINBANK World Mastercard shall constitute my / our acceptance of my / our agreement to be bound by the terms and conditions contained in the AFFINBANK World Mastercard Terms and Conditions which can be downloaded from AFFINBANK website at in the event that my / our application herein is approved. I / We further agree that I / we will be visiting AFFINBANK website from time to time for latest AFFINBANK World Mastercard Terms and Conditions. I / We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as those of the Supplementary Cardmember (if any). The Supplementary Cardmember however, shall only be responsible for his / her own liabilities and obligations. I / We further declare that the information given in this form is true and correct in full compliance with Financial Services Act 2013 (FSA). I / We also authorise AFFINBANK to make this information available to BNM in compliance with FSA. I / We shall also undertake to comply with the prevailing Foreign Exchange Administration (FEA) Rules which can be downloaded from BNM website. Bahawa urus niaga menggunakan akaun kad kredit dan wang atau dana yang digunakan untuk pembayaran balik akaun kad kredit tidak diperolehi daripada mana-mana sumber yang menyalahi undang-undang atau berkaitan dengan aktiviti-aktiviti yang menyalahi undang-undang seperti yang telah dikenal pasti di bawah Akta Pencegahan Pengubahan Wang Haram, Pencegahan Pembiayaan Keganasan dan Hasil Daripada Aktiviti Haram 2001(AMLA). Saya / Kami mengakui bahawa adalah menjadi syarat Bank Negara Malaysia (BNM) bahawa semua maklumat yang berkaitan dengan permohonan ini, sama ada berjaya atau tidak, mesti dikemaskinikan dan / atau dihantar ke Sistem Maklumat Kad Kredit (CCRIS), iaitu pangkalan data yang dikendalikan oleh BNM. Page 4 of 8
5 Saya / Kami bersetuju bahawa sebaik sahaja saya / kami menandatangani / menggunakan Kad AFFINBANK World Mastercard, saya / kami terikat kepada terma dan syarat yang termaktub di dalam Terma dan Syarat AFFINBANK World Mastercard yang boleh dimuat turun dari laman sesawang AFFINBANK di sekiranya permohonan ini diluluskan. Saya / Kami seterusnya bersetuju bahawa saya / kami akan melawat laman sesawang AFFINBANK dari semasa ke semasa untuk Terma dan Syarat AFFINBANK World Mastercard terkini. Saya / Kami seterusnya bersetuju bahawa Ahli Kad Utama hendaklah bertangungjawab terhadap semua liabiliti dan kewajipan Ahli Kad Utama serta Ahli Kad Tambahan (jika ada). Walaubagaimanapun, Ahli Kad Tambahan akan hanya bertanggungjawab terhadap liabiliti dan kewajipannya sendiri. Saya / Kami mengaku bahawa maklumat yang diberikan dalam borang ini adalah benar dan betul mematuhi sepenuhnya Akta Perkhidmatan Kewangan 2013 (FSA). Saya / Kami juga membenarkan AFFINBANK untuk memberi maklumat ini kepada BNM sebagai mematuhi FSA. Saya / Kami juga hendaklah mengaku janji untuk mematuhi Peraturan Pentadbiran Pertukaran Asing (FEA) yang boleh dimuat turun dari laman sesawang BNM. CONSENT FOR CREDIT CHECKS / KEBENARAN BAGI PENYEMAKAN KREDIT a. I / We hereby authorise AFFINBANK to disclose my / our personal data to any credit reporting agency in Malaysia to conduct credit checks on me/us from time to time in connection with the application, distribution and provision of products and/or services regardless of the relationship between me / us and AFFINBANK may have been terminated and / or an event of default had occurred. c. d. a. c. d. I / We agree that the purpose indicated by AFFINBANK of a legitimate interest to request for my / our report shall be sufficient and adequate proof of a valid purpose within the meaning of the Credit Reporting Agencies Act I / We hereby give my/our consent to CTOS, FIS, CCRIS and other credit reporting agency, a registered credit reference agency under the Credit Reporting Agencies Act 2010, to release my / our credit report to AFFINBANK and / or their legal representatives for the purposes of enabling the processing of a facility or transaction and any related processes arising there from including but not limited to credit evaluation, monitoring, credit reviews and debt recovery purposes (hereinafter referred to as legitimate interests ), offered by AFFINBANK to me / us or to a party to whom I/we have agreed to guarantee from time to time. Where AFFINBANK requires any such processing to be further processed by its Head Office or any processing centre located outside Malaysia, I / we hereby give my/our consent to CTOS, FIS, CCRIS and other credit reporting agencies to make such disclosure of my/our credit report to such locations outside Malaysia. Saya / Kami dengan ini memberi kuasa kepada AFFINBANK untuk mendedahkan maklumat peribadi saya / kami kepada mana-mana agensi pelaporan kredit di Malaysia untuk melakukan semakan kredit ke atas saya / kami dari semasa ke semasa berkaitan dengan permohonan, pengagihan dan peruntukan produk dan / atau perkhidmatan, tanpa mengambil kira perhubungan di antara saya / kami dan AFFINBANK telah ditamatkan dan/atau di dalam keadaan di mana pengingkaran telah berlaku. Saya / Kami bersetuju bahawa tujuan dinyatakan oleh AFFINBANK berkenaan kepentingan sah untuk meminta laporan saya / kami adalah mencukupi dan merupakan bukti yang memadai bagi tujuan sah selaras dengan pengertian dalam Akta Agensi Pelaporan Kredit Saya / Kami dengan ini memberi kebenaran saya/kami kepada CTOS, FIS, CCRIS dan lain-lain agensi pelaporan kredit, agensi rujukan kredit berdaftar di bawah Akta Agensi Pelaporan Kredit 2010, untuk memberi laporan kredit saya / kami kepada AFFINBANK dan / atau kepada wakil-wakil mereka yang sah bagi maksud membolehkan pemprosesan kemudahan atau transaksi dan apa-apa proses yang berkaitan yang timbul daripadanya termasuk tetapi tidak terhad kepada penilaian kredit, pemantauan, semakan kredit dan tujuan tuntutan semula hutang (selepas ini dirujuk sebagai kepentingan sah ), yang ditawarkan oleh AFFINBANK kepada saya / kami atau kepada pihak yang mana saya / kami bersetuju menjamin dari semasa ke semasa. Dimana AFFINBANK memerlukan pemprosesan tersebut untuk diproses lebih lanjut oleh Ibu Pejabat atau mana-mana pusat pemprosesan yang terletak di luar Malaysia, saya / kami dengan ini memberi kebenaran saya / kami kepada CTOS, FIS, CCRIS dan lain-lain agensi pelaporan kredit untuk membuat pendedahan laporan kredit saya / kami di kawasan di luar Malaysia tersebut. CONSENT FOR DIRECT MARKETING AND OTHERS / KEBENARAN UNTUK PEMASARAN LANGSUNG DAN LAIN-LAIN I / We consent for Affin Holdings Berhad Group ("AHB Group") (as defined in the Group Privacy Notice) and their authorized service providers collecting, using, disclosing and / or processing my / our personal data, and sharing such personal data with partners within the AHB Group (as may be applicable, depending on the products or services which I / we may have applied for or potentially benefit for), as well as advertisements, promotions and events, conduct consumer or market research and identify products and services which may be relevant to me / us (Promotional Purposes). I / We understand and agree on the above terms and conditions and is fully aware that the complete Group Privacy Notice is available by walk-in at any AHB Group offices or branches or on the website at and I / we have the full rights to decide otherwise. Note:If you are an existing customer, your previous choice remains unless if you wish to decide otherwise. By signing this form, I / we further confirm that all personal data that I / we have provided are all true, up-to-date and accurate. Should there be any changes to any of my / our personal data, I / we shall notify the relevant company in AHB Group where my / our account is maintained immediately. Notwithstanding the aforementioned where request is made by me/us for the Bahasa Malaysia version, AFFINBANK shall provide the same to me / us. Saya / Kami membenarkan pihak Kumpulan Affin Holdings Berhad ("Kumpulan AHB") (seperti yang tertakluk dalam Notis Privasi Kumpulan) dan manamana pihak lain yang dibenarkan oleh Kumpulan AHB untuk mengumpul, mengguna, mendedah dan/atau memproses data peribadi saya / kami, dan berkongsi maklumat / data peribadi tersebut kepada rakan kongsi di dalam Kumpulan AHB (mana-mana yang berkaitan, bergantung kepada produk atau perkhidmatan yang telah dipohon atau berpotensi mendapat keuntungan dari), serta pengiklanan, acara, promosi, mengadakan penyelidikan tentang pengguna atau pasaran dan mengenal pasti produk atau perkhidmatan yang mungkin sesuai untuk saya / kami (Tujuan Promosi). Saya / Kami faham dan bersetuju dengan terma dan syarat di atas dan sepenuhnya mengetahui bahawa Privasi Notis Kumpulan boleh didapati dengan mengunjungi mana-mana pejabat atau cawangan Kumpulan AHB ataupun melalui laman sesawang di dan jika sebaliknya, saya / kami mempunyai hak untuk menarik balik kebenaran tersebut. Nota: Sekiranya anda adalah pelanggan sedia ada, pilihan anda sebelumnya adalah kekal melainkan anda meminta sebaliknya. Dengan menandatangani borang ini, saya / kami telah dengan lanjut mengesahkan bahawa semua data peribadi yang saya / kami telah berikan adalah benar, terkini dan tepat. Jika terdapat sebarang perubahan kepada mana-mana data peribadi saya / kami, saya / kami akan memaklumkan kepada kepada syarikat di Kumpulan AHB di mana akaun saya / kami disimpan dengan kadar segera. Walau apa pun yang dinyatakan di atas di mana permintaan dibuat oleh saya / kami untuk versi Bahasa Malaysia, AFFINBANK hendaklah memberikannya kepada saya / kami. Disclosure / Pendedahan I / We consent to the disclosure of any documents and information relating to my / our accounts or affairs to AFFINBANK, its officers and agents and to all such persons and for all such purposes as set out in relevant Sections of the Financial Services Act 2013 (FSA). Saya / Kami bersetuju dengan pendedahan apa-apa dokumen dan maklumat yang berhubungan dengan akaun atau perihal saya / kami kepada AFFINBANK, pegawai-pegawainya dan ejen-ejen dan kepada semua orang tersebut dan bagi segala maksud seperti yang dinyatakan dalam seksyenseksyen berkaitan dalam Akta Perkhidmatan Kewangan 2013 (FSA). Page 5 of 8
6 The particulars are as below:/butir-butir adalah seperti di bawah : VERSION-3/JAN/2018/WC/APPS Declaration / Perakuan I / We understood that all references to FSA in the subsequent contractual agreements entered between me / us and AFFINBANK shall refer to the FSA and all guidance, standards or prescriptions or to be issued by Bank Negara Malaysia (BNM) at any time and from time to time. I / We confirm that I / we have not withheld any information which may prejudice my / our loan / financing application or have a bearing on AFFINBANK s financing/loan decision including but not limited to contravention of the Guidelines on Credit Transactions and Exposures with Connected Parties' issued by BNM and / or any other applicable guidance, standards or prescriptions issued or to be issued by BNM with respect to the same. I / We declare that I / we have not committed or is involved in any act of bankruptcy or is adjudged as bankrupt; or in any unlawful activities which related directly or indirectly to any serious offence in Malaysia including AMLA, FSA and Foreign Exchange Administration (FEA) Rules (including all amendments thereof) or any other related acts or regulations; or any foreign serious offence. Saya / Kami memahami bahawa semua rujukan kepada FSA dalam perjanjian kontrak berikutnya di antara saya / kami dan AFFINBANK hendaklah merujuk kepada FSA dan semua panduan, piawaian atau preskripsi yang dikeluarkan atau akan dikeluarkan oleh Bank Negara Malaysia (BNM) pada bilabila masa dan dari semasa ke semasa. Saya / Kami mengesahkan bahawa saya / kami tidak menyembunyikan apa-apa maklumat yang boleh menjejaskan pinjaman / permohonan pembiayaan saya / kami atau mempunyai kaitan dengan keputusan pembiayaan / pinjaman AFFINBANK termasuk tetapi tidak terhad kepada pelanggaran 'Garis Panduan mengenai Urus Niaga Kredit dan Pendedahan dengan Pihak Yang Berkaitan yang dikeluarkan oleh BNM dan/atau mana-mana panduan lain yang berkenaan, piawaian atau preskripsi yang dikeluarkan atau yang akan dikeluarkan oleh BNM berkenaan dengan yang sama. Saya / Kami mengesahkan bahawa saya / kami tidak melakukan atau terlibat dalam apa-apa perbuatan kemuflisan atau dihukum sebagai muflis; atau dalam apa-apa aktiviti yang menyalahi undang-undang yang berkaitan, secara langsung atau tidak langsung terhadap apa-apa kesalahan serius di Malaysia termasuk AMLA, FSA dan Peraturan Pentadbiran Pertukaran Asing (FEA)(termasuk semua pindaan) atau apa-apa tindakan yang berkaitan atau peraturan-peraturan lain; atau apa-apa kesalahan serius di luar negara. I (Principal Cardmember) hereby further declare that (no declaration from the applicant denotes that this declaration is not applicable). / Saya (Ahli Kad Utama) dengan ini mengisytiharkan selanjutnya bahawa (tiada pengakuan daripada pemohon menandakan bahawa pengakuan ini tidak berkenaan). I am a staff of AFFINBANK / AFFIN ISLAMIC BANK. / Saya adalah kakitangan AFFINBANK / AFFIN ISLAMIC BANK. To the best of my knowledge, I have close relative(s)* employed under AFFINBANK / AFFIN ISLAMIC BANK. / Sepanjang pengetahuan saya, saya mempunyai saudara terdekat* yang bekerja di bawah AFFINBANK / AFFIN ISLAMIC BANK. Name / Nama IC No. / No. KP Relationship / Hubungan * Close relative(s) include spouse of staff and dependents of spouse, child (including step child and adopted child), parent(s), brother or sister and their spouses and any other dependents and persons who may influence/be influenced by the staff or as defined under the BNM s Guidelines on Credit Transactions and Exposures with Connected Parties. * Saudara terdekat termasuk pasangan kakitangan dan tanggungan suami atau isteri, anak (termasuk anak tiri dan anak angkat), ibu bapa, saudara lelaki atau perempuan dan suami atau isteri mereka dan mana-mana orang tanggungan dan orang lain yang mungkin mempengaruhi/dipengaruhi oleh kakitangan atau sebagaimana yang ditakrifkan di bawah Garis Panduan BNM mengenai Urus Niaga Kredit dan Pendedahan dengan Pihak Yang Berkaitan. I / We further understood that any sum set out in this application or in the subsequent agreement or otherwise payable by any party hereto to any other party pursuant to this application or subsequent agreement shall be deemed to be exclusive of any Goods and Services Tax (GST) or tax of similar nature which is chargeable on the supply (or supplies) for which such sum is (the whole or part of) the consideration for GST purposes. AFFINBANK s charges shall exclude tax that would be imposed in the future (including but not limited to GST). Upon implementation of the GST, AFFINBANK will be entitled to recover from me / us any GST that AFFINBANK are required by law to collect. Saya / Kami juga memahami bahawa apa-apa jumlah yang dinyatakan dalam permohonan ini atau dalam perjanjian yang berikutnya atau dibayar oleh mana-mana pihak kepada mana-mana pihak lain di bawah permohonan ini atau perjanjian yang kemudiannya hendaklah disifatkan sebagai tidak termasuk sebarang Cukai Barang dan Perkhidmatan (CBP) atau cukai yang serupa yang mana dikenakan ke atas pembekalan (atau bekalan) yang mana jumlah wang tersebut (keseluruhan atau sebahagian daripadanya) balasan bagi tujuan CBP. Caj-caj yang dikenakan oleh AFFINBANK hendaklah tidak termasuk cukai yang akan dikenakan pada masa akan datang (termasuk tetapi tidak terhad kepada CBP). Apabila CBP dilaksanakan, AFFINBANK berhak untuk mendapatkan daripada saya / kami apa-apa CBP sebagaimana dikehendaki oleh undang-undang. I / We further understand that: a. AFFINBANK acceptance of my / our application herein does not constitute approval and if approved by AFFINBANK, it is subject to revision, reduction or cancellation at any time at AFFINBANK s absolute discretion without stating any reasons whatsoever; c. d. this application and supporting documents remain AFFINBANK s property regardless whether the application is approved or rejected by AFFINBANK. I / We have read and understood the above terms and conditions for this application. I / We hereby undertake and agree to be bound by AFFINBANK s terms and conditions as mentioned herein and the said terms and conditions shall form part and parcel of the security documents executed in AFFINBANK s favour. Saya / Kami seterusnya memahami bahawa: a. penerimaan permohonan saya / kami oleh AFFINBANK di dalam ini tidak menjaminkan kelulusan dan jika diluluskan oleh AFFINBANK, ia tertakluk kepada penilaian semula, pengurangan atau pembatalan pada bila-bila masa mengikut budi bicara mutlak AFFINBANK tanpa menyatakan apa-apa sebab sekalipun; c. d. I / we understand that AFFINBANK reserves the right to decline an application without giving any reasons; all other terms and conditions not specifically mentioned above are to be incorporated in the AFFINBANK World Mastercard Terms and Conditions; and saya / kami memahami bahawa AFFINBANK berhak untuk menolak permohonan tanpa memberi sebarang sebab; semua terma dan syarat lain yang tidak disebut secara khusus di atas hendaklah dimasukkan di dalam Terma dan Syarat AFFINBANK World Mastercard; dan permohonan dan dokumen-dokumen sokongan akan kekal sebagai harta AFFINBANK tanpa mengira sama ada permohonan diluluskan atau ditolak oleh AFFINBANK. Page 6 of 8
7 Saya / Kami telah membaca dan memahami terma dan syarat di atas untuk permohonan ini. Saya / Kami dengan ini mengakujanji dan bersetuju untuk terikat dengan terma-terma dan syarat-syarat AFFINBANK sebagai yang dinyatakan di sini dan terma-terma dan syarat-syarat tersebut akan menjadi sebahagian daripada dokumen-dokumen keselamatan dilaksanakan bagi pihak AFFINBANK. DECLARATION ON PRODUCT DISCLOSURE SHEET / PERAKUAN MENGENAI LEMBARAN MAKLUMAT PRODUK I / We have read and understood the information, fees and charges as stated in the Product Disclosure Sheet and agree to abide to its terms and conditions. / Saya / Kami telah membaca dan memahami sepenuhnya maklumat, yuran dan caj-caj yang tertera di dalam Lembaran Maklumat Produk dan bersetuju untuk mematuhi terma dan syarat berkaitan dengannya. Signature of Principal Card Applicant / Tandatangan Pemohon Kad Utama Signature of Supplementary Card Applicant / Tandatangan Pemohon Kad Tambahan Date / Tarikh : - - Date / Tarikh : - - FOR BANK USE ONLY / UNTUK KEGUNAAN BANK SAHAJA Name of agent / Staff / Nama Ejen / Kakitangan Staff PS No. / No. PS Kakitangan Referral PS No. / No. PS Perujuk For Cards Business Department use only / Untuk kegunaan Jabatan Perniagaan Kad Vetted by / Disemak oleh Input by / Dimasukkan oleh Checked by / Diperiksa oleh Team Code / Kod Kumpulan Delivery Channel / Saluran Serahan Branch Code / Kod Cawangan Source Code / Kod Sumber Promotion Program / Program Promosi Page 7 of 8
8 DOCUMENTS / DOKUMEN a. Salaried employee / Kakitangan bergaji Photocopy of IC (both sides) or passport with valid Visa permit (for non-malaysian applicant) for both principal and supplementary applicants / Salinan KP (depan & belakang) atau pasport dengan permit Visa yang sah (untuk pemohon bukan rakyat Malaysia), untuk kedua-dua pemohon kad utama dan tambahan Latest 1 month salary slip (compulsory), and any one of the following documents: / 1 bulan penyata gaji terkini (wajib), dan salah satu daripada dokumen-dokumen yang berikut: i. Copy of latest EPF statement; or / Salinan terkini penyata KWSP; atau ii. iii. Copy of latest 1 month bank account statement where the salary is credited; or / Salinan terkini 1 bulan penyata akaun bank dimana gaji dikreditkan; atau Latest BE Form / B Form with tax payment receipt / Borang BE / Borang B terkini disertai resit bayaran cukai pendapatan Self Employed / Bekerja Sendiri Photocopy of IC (both sides) or passport with valid Visa permit (for non-malaysian applicant) for both principal and supplementary applicants / Salinan KP (depan & belakang) atau pasport dengan permit Visa yang sah (untuk pemohon bukan rakyat Malaysia), untuk kedua-dua pemohon kad utama dan tambahan i. Self Employed (Bank s customer of more than 6 months) / Bekerja Sendiri (Pelanggan Bank selama lebih 6 bulan) Form 9, Form 24 & Form 49 or Business Registration Certificate / Borang 9, Borang 24 & Borang 49 atau Sijil Pendaftaran Perniagaan ii. Self Employed (Non-Bank customer) / Bekerja Sendiri (Bukan Pelanggan Bank) Form 9, Form 24 & Form 49 or Business Registration Certificate / Borang 9, Borang 24 & Borang 49 atau Sijil Pendaftaran Perniagaan Latest BE Form / B Form with tax payment receipt and any of the following: / Borang BE / Borang B terkini disertai resit bayaran cukai pendapatan dan salah satu di antara yang berikut: i. ii. c. Commission Earner / Pendapatan Komisen Copy of latest 6 months account statement where the commission is credited; or / Salinan terkini 6 bulan penyata akaun bank dimana komisen dikreditkan; atau Latest EA Form / BE Form with tax payment receipt and E-Filling Acknowledgment / Borang EA / Borang BE terkini disertai resit bayaran cukai pendapatan dan akuan penerimaan E-Filling Please note that the enclosed documents are non-returnable. For security purpose, please cross all the documents submitted. / Sila ambil perhatian bahawa dokumen yang dilampirkan tidak akan dikembalikan. Bagi tujuan keselamatan, sila palangkan semua dokumen-dokumen yang dihantar. ANNUAL FEES / YURAN TAHUNAN Latest 3 months company s account statement; or / Salinan terkini 3 bulan penyata akaun syarikat; atau Latest Profit & Loss Account statement / Penyata Akaun Untung dan Rugi terkini Photocopy of IC (both sides) or passport with valid Visa permit (for non-malaysian applicant) for both principal and supplementary applicants / Salinan KP (depan & belakang) atau pasport dengan permit Visa yang sah (untuk pemohon bukan rakyat Malaysia), untuk kedua-dua pemohon kad utama dan tambahan Latest 6 months commission statements / 6 bulan penyata komisen terkini First Year / Tahun Pertama Second Year Onwards / Tahun Kedua dan Seterusnya Principal Card / Kad Utama Supplementary Card / Kad Tambahan * Annual fee for second year onwards will be waived subject to the following spend conditions: * Pengecualian yuran tahunan tahun kedua dan seterusnya adalah tertakluk kepada syaratsyarat perbelanjaan yang berikut: Waived / Dikecualikan RM530 per annum / setahun RM424 per annum / setahun RM48,000 per annum / setahun Note: Annual fees above are inclusive of GST 6% / Nota: Yuran tahunan di atas adalah termasuk CBP 6%. **Minimum spending is inclusive of retail and cash advance transactions. / Perbelanjaan minimum adalah termasuk transaksi runcit dan pendahuluan tunai. Page 8 of 8
Marital Status / Status Perkahwinan : Single / Bujang Married / Berkahwin Divorced / Bercerai Widow / Balu. Copyright 2018 Affin Bank Berhad (25046-T)
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