BSN MyAuto/i APPLICATION FORM BORANG PERMOHONAN BSN MyAuto/i
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1 BSN MyAuto/i APPLICATION FO BORANG PEOHONAN BSN MyAuto/i Islamic / Islamik Individual / Individu Conventional / Konvensional NonIndividual / Bukan Individu New Variation Assignment Scheme / Skim : Registered in Sabah / Sarawak : CA No : Branch Code / Kod Caw Staff ID Together with this application, I wish to apply for / Bersama dengan permohonan ini, saya ingin memohon BSN Credit Card / Kad Kredit BSN ASB Loan / Pinjaman ASB 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 A l APPLICANT DETAILS / MAKLUMAT PEMOHON PERSONAL/COMPANY DETAILS MAKLUMAT PERIBADI / SYARIKAT Name / Nama / NRIC No No Kad Pengenalan Mobile Phone No No Tel Bimbit Residential Phone No No Tel Kediaman / Emel Old IC No No KP Lama Business Reg No No Syarikat Gender Jantina Race Bangsa Male / Lelaki Female / Perempuan Malay Melayu Marital Status Status Perkahwinan Chinese Cina Single Bujang Bumiputera Indian India Married Berkahwin 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) / EMPLOYMENT DETAILS / MAKLUMAT PEKERJAAN Education Level / Tahap Pendidikan Certificate / Sijil Diploma / Diploma Degree / Ijazah / Office Phone No / No Tel Pejabat Office / Emel Pejabat Office Fax No / No Faks Pejabat Employment Status Status Pekerjaan Company Type Jenis Syarikat Business Type / Jenis Perniagaan Employed / Bekerja Permanent / Tetap Contract / Kontrak Govt ncies nsi Kerajaan Statutory Body Badan Berkanun Self employed / Bekerja Sendiri Professional / Profesional Nonprofessional / Bukan Professional Financial Institution Institusi Kewangan Govt Linked Corporation Sykt Berkaitan Kerajaan Unemployed / Tidak bekerja With other income / Mempunyai sumber pendapatan lain Without any other income / Tiada sebarang sumber pendapatan KLSE Listed Sykt Awam Bhd Private Limited Sdn Bhd Company Size / Saiz Syarikat Small (<15 employees) / Kecil (<15 orang pekerja) Medium (1550 employees) / Sederhana (1550 orang pekerja) Large (>50 employees) / Besar (>50 orang pekerja) Previous Terdahulu Length of Service Tempoh Perkhidmatan Years Tahun
2 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/ ibubapa adalah pekerja BSN atau manamana 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 Financing Amount Applicant / Guarantor Monthly Installment Current Balance Jenis Pembiayaan Jumlah Pembiayaan Pemohon / Penjamin Ansuran Bulanan Baki Pembiayaan Semasa End Date of Financing Tarikh Tamat Pembiayaan Existing BSN Financing Acc No / No Akaun Pembiayaan BSN Sedia Ada Other Source of Income / Sumber Pendapatan Facility / Financing Payment Fasiliti / Pembayaran Pembiayaan Salary Deduction / Potongan Gaji Nonsalary Deduction / Tanpa Potongan Gaji Amount declared per month / Jumlah diisytiharkan setiap bulan Bank Account / Akaun Bank Bank Account / Akaun Bank Branch / Cawangan Account No / No Akaun Are you engaged in the business of motor trade? / Adakah anda terlibat dalam perniagaan perdagangan motor? B l GUARANTOR DETAILS / MAKLUMAT PENJAMIN ( if required / jika diperlukan) / Relationship With Applicant / Hubungan Dengan Pemohon NRIC No No Kad Pengenalan Mobile Phone No No Tel Bimbit Residential Phone No No Tel Kediaman Old IC No No KP Lama Guarantor's Name / Nama Penjamin Business Reg No No Syarikat Gender Male / Lelaki Jantina Female / Perempuan Race Malay Bangsa Melayu Marital Status Status Perkahwinan Chinese Cina Single Bujang Bumiputera Indian India Married Berkahwin Education Level / Tahap Pendidikan Certificate / Sijil Diploma / Diploma Degree / Ijazah / Permanent Address / Alamat Tetap No of dependents Bil Tanggungan Office Phone No / No Tel Pejabat Office Fax No / No Faks Pejabat C l REFEREES DETAILS / MAKLUMAT PERUJUK (NOT LIVING WITH APPLICANT / TIDAK TINGGAL BERSAMA PEMOHON) Name / Nama / Relationship With Applicant / Hubungan Dengan Pemohon Mobile Phone No No Tel Bimbit Residential Phone No No Tel Kediaman
3 D l SPOUSE DETAILS / MAKLUMAT PASANGAN Spouse's Name / Name Pasangan NRIC No No KP Old IC No No KP Lama Business Reg No No Syarikat Mobile Phone No No Tel Bimbit Office Phone No No Tel Pejabat Length of Service Tempoh Perkhidmatan Years Tahun E l FINANCIAL AND VEHICLE DETAILS / MAKLUMAT PEMBIAYAAN DAN KENDERAAN Deal Type / Jenis Urusan Dealer / Pengedar Direct Case / Kes Langsung Dealer's Name / Nama Pengedar Seller's Name / Nama Penjual Vehicle Make / Pengeluar Kenderaan Vehicle Model / Model Kenderaan Model Year / Tahun Pengeluaran Vehicle Condition / Kondisi Kenderaan Registration No / No Pendaftaran Engine Capacity / Kapasiti Enjin (cc) New / Baru Recond (Unregistered) Used / Terpakai Is the vehicle imported? / Adakah kenderaan ini diimport? Date of Registration (ddmmyyyy) / Tarikh Pendaftaran (hhbbtttt) Registration Location / Lokasi Pendaftaran Semenanjung Labuan Sabah / Sarawak Langkawi Fuel Type / Jenis Bahan Api Petrol Diesel / Hybrid Chassis No / No Casis Vehicle Price / Harga Kenderaan Deposit/ Deposit Amount Financed/ Jumlah Pembiayaan Interest / Profit Rate Kadar Faedah / Keuntungan Location of Storage of Goods Lokasi Penyimpanan Kenderaan F l BUNDLING PRODUCTS / PROMOSI PRODUK % Ansuran Bulanan CREDIT CARD APPLICATION / PEOHONAN KAD KREDIT 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 Classic Home Rumah BSN MasterCard Platinum BSN MasterCard Gold BSN MasterCard Classic 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) Office Pejabat Engine No / No Enjin Tenure (Months) / Tempoh (Bulan) Term Charges / Caj Berjangka Monthly Installments / Total Payable / Jumlah perlu dibayar CoBrand Cards / Kad Jenama Bersama: 1 TEACHERSCARD MasterCard Gold AIAFAMBSN Visa Platinum Business Other BSN Credit Card UUM BSN MasterCard Platinum UUM BSN MasterCard Gold 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 / Emel Collect at Branch / Pengambilan kad di Cawangan ASB LOAN / FINANCING APPLICATION / PEOHONAN PINJAMAN / PEMBIAYAAN ASB Loan / Financing Amount / Amaun Pinjaman / Pembiayaan Tenure (Months) / Tempoh (Bulan)
4 G l DECLARATION / DEKLARASI FOR ALL PRODUCTS / UNTUK SEMUA PRODUK 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 syaratsyarat 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 / No 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 apaapa cara yang disenaraikan dibawah: (a) I am not related/ connected to any employee, director of BSN or any of its subsidiary Saya tidak mempunyai sebarang pertalian dengan manamana 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 apaapa 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 apaapa urus niaga komersial, kontrak atau urusan penyumberan luar dengan BSN atau anak syarikatnya * "family members" refers to spouse, parent, parent inlaw, 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, adikberadik lelaki dan perempuan serta ipar atau manamana 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 apaapa maklumat berkaitan permohonan ini kepada manamana 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 Bankbank Malaysia atau manamana pihak berkuasa lain, termasuk manamana anak syarikat Bank dan manamana 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 apaapa maklumat saya yang relevan untuk tujuan jualan silang, pemasaran dan aktiviti promosi dengan manamana 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 apaapa maklumat saya yang relevan untuk tujuan jualan silang, pemasaran dan aktiviti promosi dengan manamana pihak h I have read and agreed with the Bank Privacy Notice which can be obtained from the wwwmybsncommy Saya telah membaca dan bersetuju dengan Notis Privasi Bank yang boleh diperolehi dari wwwmybsncommy 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 relevant Anti Money Laundering, AntiTerrorism Financing and Proceeds of Unlawful Activities Act 2001 requirements Saya dengan ini mengaku janji bahawa saya tidak akan menggunakan fasiliti ini untuk menyalurkan apaapa hasil daripada aktivitiaktiviti haram dan saya juga bersetuju untuk membekalkan semua maklumat dan dokumendokumen, 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 2001 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 us 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
5 FOR BSN MyAuto/i / UNTUK BSN MyAuto/i k Upon delivery of the vehicle, I hereby agree to waive any rights, claim or demand pertaining to the deposit amount [inclusive of booking fee] and I hereby will indemnify and keep BSN indemnified from any claim or demand whatsoever related thereto Setelah penghantaran kenderaan, saya dengan ini bersetuju untuk mengetepikan apaapa hak, tuntutan atau permintaan mengenai jumlah deposit [termasuk fi tempahan] dan saya akan menanggung rugi BSN dari apaapa tuntutan atau apa jua permintaan yang berkaitan dengannya 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 theretoth is application shall form my agreement with BSN for the use of my BSN Visa/MasterCard Credit Card Saya bersetuju kepada segala termaterma dan syaratsyarat 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 perl u dibayar kepada Bank yang timbul berhubung penggunaan Kad Utama atau Kad Tambahan (Supplementary Card) yang disediakan c YES, I/We have read and agreed on the content stated in the Product Disclosure Sheet (PDS) obtained from the Bank (Via Sales Executive, Branch or wwwmybsncommy) / YA, saya/kami telah membaca dan bersetuju dengan isi kandungan Penyata Pendedahan Produk (PPP) yang diperolehi daripada Bank (melalui Eksekutif Jualan, Cawangan atau wwwmybsncommy) FOR ASB LOAN / FINANCING / UNTUK PINJAMAN ASB a I confirmed that I have read, understood and hereby agree to abide by the terms and conditions of the BSN ASB Loan Agreement and any changes thereto in the future Saya mengesahkan bahawa telah membaca, memahami dan bersetuju untuk tertakluk kepada segala termaterma dan syaratsyarat Perjanjian Pinjaman ASB BSN dan sebarang pertukaran pada masa akan datang Applicant's Signature / Tandatangan Pemohon Guarantor's Signature / Tandatangan Penjamin H l FOR BANK USE ONLY/ UNTUK KEGUNAAN BANK SAHAJA To be filled by BSN representative / Untuk diisi oleh wakil BSN I hereby declare that the followings are true and correct to the best of my knowledge : Saya dengan ini mengisytiharkan berikut adalah benar dan betul berdasarkan pengetahuan saya : 1 I have sighted the Identity Card for both the applicant and guarantor Saya telah melihat Kad Pengenalan untuk keduadua pemohon dan penjamin 2 I have verified that the information furnished by the customer is true and correct to the best of my knowledge Saya telah mengesahkan bahawa maklumat yang diberikan oleh pelanggan adalah benar dan betul berdasarkan pengetahuan saya 3 I confirmed that the financing application form was signed by the customer Saya mengesahkan bahawa borang permohonan pembiayaan telah ditandatangani oleh pelanggan Staff's Signature and Stamp / Tandatangan dan Cop Kakitangan
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