Online Debit Card Application Form

PB Card Online Application Customer Copy Reference Number : OA0718133565

CARD SELECTION

Card Type

PB Visa Electron (D1YWWB1204)

PERSONAL DATA OF PRINCIPAL CARDMEMBER

NRIC (Old) NRIC (New)

A1234997 681226-02-5443

Name (as per NRIC/Passport) Email Address

Azhar Bin Ramli [email protected]

RESIDENCE

Address

Batu 19, Jalan Kuala Nerang

State Post Code

Kedah 06300

DECLARATION

DECLARATION BY NON-MALAYSIAN APPLICANT (TICK WHERE APPROPRIATE) No, I/my immediate family members Yes, I/my immediate family members Position

do not hold

have never held Senior Public Office

currently hold

have held Date

to

held

I/We confirm that all the above information is true and complete and authorise the Bank to verify from whatever sources the Bank may consider appropriate including Inland Revenue Board. I/We acknowledge that the Card may only be used subject to the Terms and Conditions of the PB Visa Cardmember Agreement and agree to be bound by the Terms and Conditions of the Card. I/We agree to pay the prevailing annual fees upon approval and shall accept joint and several liability for all charges on my/our Card Account(s) with the Bank. The Bank shall reserve the absolute right to approve or reject my/our application as the Bank deems fit without assigning any reason. I/We irrevocably consent to and authorise the Bank to disclose to Bank Negara Malaysia, any authority/body having jurisdiction over the Bank, any guarantor(s)/security parties, and/or its lawyers or any other debt collection agent, companies which are related to the Bank by virtue of Section 6 of the Companies Act 1965 at any time and without notice or liability any information relating to my/our affairs, banking accounts or conduct thereof (including my/our credit standing) to such extent and for such purposes as the Bank may in its absolute discretion deems necessary or expedient.

Please sign here with dark black ink only. Signature must not exceed box boundaries. SIGNATURE: PRINCIPAL CARD APPLICANT

Thank you for applying via the

PB Card Online Application. To expedite processing, please remember to enclose the signed PB Card Online Application Customer Copy together with the following documents for submission to us: Documents to be submitted: * Photostat copy of your NRIC (both sides) or Passport for NonMalaysians; and * Photostat copy of you Work Permit/Student Pass (for NonMalaysian only). Note: 1)Documents submitted are non returnable. 2)If the above required documents do not reach PB Card Services within 30 days from the date the PB Card Online Application Form is submitted, your application will be cancelled automatically. Address PB Card Services 10th Floor, Menara Public Bank, 146 Jalan Ampang, P.O. Box 11722, 50754 Kuala Lumpur Tel. No. : 03-2176 8000 Fax No. : 03-2163 9400