4) DirectDebit

AUTHORIZATION FORM
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IMPORTANT NOTE: ALL FIELDS WITH T} ARE MANDATORY, PLEASE USE CAPITAL LETTERS, BLACK INK AND tr oN rse RELEVANT BoxEs.

Tvpe of Application " il New Application T Maintenance I Terrnination

Account Holder's
Name (Primary) -

lD Number I rlew tc I Rassport

(withatt'-' or't") *
t oro rc
n
L-l
Business
Req.
Saving, Current or Card
Account No {without':
or'/') "
Bank Abbreviation *
Telephone l.lumber (Refer to Guideline for abbreviation list)

E-Mail

Purpose of Fayment *

Maximum amount to debit per (Subject to maximum limit specified by

transaction (RM)" the DD Operator]

lvlaximum
Mode of frequency " Daily Weekly fvlonthly Yearly
frequency *

Effective Date * j': l

Expiry Date :,::
.t
,'1, 1.-: L.r iij
(DDMMYY) (DDMMYY)
Declaration:
a. l/We hereby acknowledge that the inforrnalion !n this form will be disclosed or released to the Corporation, Corporalion's bank and the Direct
Debit Operator for the purpose of the Direct Debit collection.
b. lAffe hereby acknowledge that a fee/charge will be charged to melus in the event mylour Account has insufficient balance to make Direct Debit
paym*nt rnstruction(s). l/We hereby agree the Bank to debit related fees/charges from mylour Acccunt as a consequence of having insufficient
fund for Direct Debit payment(s)"
c. l/VVe hereby confirm that l/we have checked the accuracy and correctness of the details furnished by me/us in this application form and llwe are
aware of the contenl and the scope of the services provided therein.
d. iANe hereby declare that all information provided is to the best of my/our knowledge true and correct.
e. lArVe hereby agree to be bound by the Terms and Conditions.
f. This Direct Debit authorization will remaln in force untii terminated by llwe with prior written notice sent to Bank/Corporation.
g" lMJe hereby ar.rthorise the Bank to debit mylour Account for the Direct Debit payment(s) including the relevant transaction fees/charges not
payable by the Corporation.

Signature 1 Company Date* ;-! 'f'

:.j :'.i
Stampt (DDMMYY)
Account Holder's Signatures as per Bank's record
\For Joint A,ccounl - Signature as per Bank's signing condilion)

Biller !D * Date"
(DDMMYY) :..: ::
Payment R.eference No. (e g. Policy No-, etc.)
(Must be unique) -

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Company Stanrpl Logo I
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{Optionai}
Prepared By iName) i
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Signature :
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500-44/aaa1 a9c4 Page I of 1 Confidential

Version 2.2