Chailease Berjaya Credit Sdn. Bhd.

(1158503-K)
A-11-01, Level 11, Block A, Jalan Barat, Seksyen 8, 46050 Petaling Jaya, Selangor

Application Form
Type of Facility: □ Hire Purchase □ Leasing
PART A. Company
Name of Company:_______________________________________________ Registration No._________________
Date of Incorp.______________ Company tel No._________________ E-Mail:______________________________
Business Address:_______________________________________________________________________________
Post Code:____________________ State:___________________ Type of Organization:______________________
Capital as at:______________ Authorized:_______________ Paid Up:__________________
Years at office address:_____ years □ own property □ mortgaged □ Rented _______MTH
Nature of Business:______________________________________
Shareholders/Directors/Partners/Sole Proprietor
Name CO. REG NO/NRIC NO Designation Shareholdings

PART B. Individual
Name:_____________________________________□ MALE □ FEMALE Date of Birth:____________
I/C Passport NO. ___________________ Education_____________________ Nationality______________
Marital Status____________(if married, fill in "PART C. Spouse) No. of Dependents__________
Home Address________________________________________________________________________________
Post Code ______________ State__________________ Contact E-Mail:__________________________________
TEL NO. of Home: _________________ TEL NO. of Office:_________________ Handphone:_________________
Years at current address: ______years□ own property □ mortgaged □ Rented _____MTH □ Parent/Relative
Occupation □ Employed □ Self-Employed Employer Name:_______________________________________
Working Address:______________________________________________________________________________
Post Code :_____________ State:_________________ Working E-Mail:__________________________________
Working TEL NO:________________ Working FAX NO:________________
Position Held______________ Monthly Income/Salary: RM__________ No of Year of Current Job: ______years
C. Spouse
Name: _________________________________ I/C Passport NO. _______________Date of Birth: ______________
Education_____________ Nationality______________
TEL NO. of Home: _________________ TEL NO. of Office:_________________ Handphone:_________________
Years at current address: ______years□ own property □ mortgaged □ Rented _____MTH □ Parent/Relative
Occupation □ Employed □ Self-Employed Employer Name:_______________________________________
Working Address:______________________________________________________________________________
Post Code :_____________ State:_________________ Working E-Mail:__________________________________
Working TEL NO:________________ Working FAX NO:________________
Position Held______________ Monthly Income/Salary: RM__________ No of Year of Current Job: ______years
D. Banking Facilities(LOANS/OVERDRAFT/LEASE/HIRE PURCHASE)
Lender & Type of Facility A/C/ Vehicle Loan Amount Bal Security
Branch No. Outstandin
g

E. Business(Supplier & Customer)/Personal Reference

Company/Indv Address Contact Tel No
name Person
F. Proposed Guarantor(s) (attachment if necessary)
Individual
Relationship with hirer:__________________ Name: ___________________ I/C Passport NO. _______________ □
MALE □ FEMALE Date of Birth:______________ Education________________ Nationality______________
Marital Status_______________
Home Address:_______________________________________________________________________________
Post Code :_______________State:_______________ Contact E-Mail:__________________________
TEL NO. of Home: _________________ TEL NO. of Office:_________________ Handphone:_________________
Occupation □ Employed □ Self-Employed Employer Name: ____________________________________
No of Year in Current Job:_______ years Position Held:__________ Monthly Income/Salary: RM____________

Corporate
Name of Company:_____________________________________________________Registration No.___________
Date of Incorp.__________ Company tel No.____________________ E-Mail:______________________________
Business Address:_____________________________________________________________________________
Post Code:_________ State:______________ Type of Organization:_______________
Capital as at:___________ Authorized:___________ Paid Up:____________________
Years at office address:_____ years □ own property □ mortgaged □ Rented _______MTH
Nature of Business:____________________________________________________________
G. Description of Goods
Supplier: Description of Goods: Purchase Cost:
____________________________ ______________________ _______________RM
_
Repayment Term:__________ Loan Amount :RM_________ Total Cost :RM______________
H. Reference(people don’t stay with you but relate to you)
Name Address Phone no. Relationship

I. Goods to be located at:_________________________________________________________________________

J. Declaration
I/We hereby declare that the information supplied in this application form is true and correct.
I/we hereby authorise you to obtain any information you may require from any source in connection with this
application.
IMPORTANT: Chailease Berjaya Credit Sdn. Bhd. Reserves the right to reject the application without assigning any
reasons thereof.

□ I/We hereby consent for Chailease Berjaya Credit Sdn. Bhd. To disclose my/our information to Chailease Berjaya
credit Sdn. Bhd.'s Affiliates and third parties, under strategic alliance for marketing and promotion.

Date:________________ SIGNATURE OF APPLICANT:________________________________________________

K. DOCUMENT TO BE SUBMITTED WITH APPLICATION FORM

1. □M&A/Business Registration/Latest SSM 8. □INCOME TAX FORM J(LAST 2 YEARS)
2. □PRACTISING CERTIFICATE, IF ANY 9. □CURRICULUM VITEA, IF ANY
3. □ FORM 24 & 49 10.□ LIST OF CONTRACTS/PROJECTS, IF ANY
4. □ BANK STATEMENT(last 6 months) 11.□IDENTITY CARD OF APPLICANT/PARTNERS-PHOTOCOPY
5. □BANK OFFER LETTER, IF ANY 12.□IDENTITY CARD OF GUARANTOR-PHOTOCOPY*
6. □AUDITED ACCOUNTS(LAST 1 YEAR) 13.□SUPPLIER QUOTATION/SALES ORDER
7. □PAYSLIP(LAST 3 Months) 14.□ANY SUPPORTING DOCUMENT
N.B.* THE ABOVEE DOCUMENT REQUIREMENT APPLIES TO INDIVIDUAL APPLICANT&PROPOSED GUARANTOR.
LETTER OF CONSENT FOR OBTAINING CREDIT INFORMATION

I/we, ____________________________ (National Registration Identification No.: ____________) of

___________________________________________ (address) hereby give my/our unconditional and unequivocal consent to:
1) CTOS Data Systems Sdn Bhd (Company No. 247651-T)
2) FIS Data Reference Sdn Bhd (Company No. 988222-H)
3) Credit Bureau Malaysia Sdn Bhd (Company No. 820050-T)
4) RAM Credit Information Sdn Bhd (Company No. 532271-T)

i. process or continue to process my/our credit information in accordance to the provisions of the Credit Reporting Agencies
Act 2010;
ii. conduct or continue to conduct credit checks on me/us for credit review, credit evaluation, debt recovery purposes, and legal
documentation consequent to contract(s) or facility(ies) granted or to be or continue to be granted by financial institution(s)
or other persons to me/us;
iii. use or continue to use the monitoring applications and obtain new information and updates on me/us and/or my/our
company(ies)/business(es) from other available sources; and
iv. disclose or continue to disclose any credit information and/or to generate credit report(s) about me/us, my/our
company(ies)/business(es) to Chailease Berjaya Credit Sdn Bhd (Company No.1158503-K)

This consent is given with the understanding that disclosure shall be limited to the business transaction(s) pertaining to credit facility
application.

By signing below, I/we hereby agree, confirm and acknowledge that I/we have been fully and duly informed and I/we have read and
understood and agree to the following:

i. I/We certify that this authorization to disclose, retrieve and/or process my/our credit information has been made voluntarily;
ii. I/We understand that I/we may revoke this consent given at any time except to the extent that the consent has already been
locked by Chailease Berjaya Credit Sdn Bhd and I/we can contact the person-in-charge to unlock it provided my/our business
transaction(s) with Chailease Berjaya Credit Sdn Bhd has been fully settled;
iii. If I/we do not sign this form or do not want to consent to the above Credit Reporting Agencies disclosing my/our credit
information to Chailease Berjaya Credit Sdn Bhd, I/we understand that the Credit Reporting Agencies will not disclose my/our
credit information to Chailease Berjaya Credit Sdn Bhd and therefore might cause the business transaction(s) which I/we have
with Chailease Berjaya Credit Sdn Bhd to be aborted, delayed or halted; and
iv. The notice as required under Section 23 of the CRA.

Acknowledged and agreed to by:

For Business For Individual

______________________ _____________________________
Company’s Name: Name:
Name of Signatory: NRIC No.:
NRIC No.: Date:
Position:
Date:
Company Stamp/Chop