To

: Operational Support Department Customer Service Division MEASAT BROADCAST NETWORK SYSTEMS SDN BHD : : : : : : : AUTHORIZATION FOR CREDIT/CHARGE CARD DEDUCTION / / 0 3

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I, _______________________________ (Tel: ) hereby authorize MEASAT Broadcast Network Systems Sdn Bhd (MBNS), to charge the amount of RM______________(Ringgit Malaysia:_________________________________________) to my credit card for the payment of amounts due to MBNS. This payment is made for:My own account On behalf of above mentioned Subscriber, if different Reconnection Required The following are my credit card details (please tick the card type):Card Type Card Number Expiry Date Issuing Bank : : : : M M / Y Y Y Y Amex Diners Visa MasterCard

For all future billings
Yes, charge the subscription fees and any amounts that may be due to MBNS to my credit card stated above and any renewal or replacement thereof. No, do not charge to my credit card for any other payment than that authorised above

Kindly proceed as per my instructions above. Yours sincerely, Signature: Card Holder’s Name: NRIC No: Credit card details verified by MBNS Officer Signature : Officer’s Name : NRIC No. :

Please note that payment shall only be deemed received upon approval from the Credit Card Issuer.

For MEASAT Broadcast Network Systems Sdn Bhd – Remittance Unit use Only Transaction result : Successful / Unsuccessful Attended By : Date :

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