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11/6/2014 Public BankBerhad - PB-Esso Mobil Visa Debit Card

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PB Card Online Application Customer Copy
Reference Number : OA14162000030

CARD SELECTION

Card Type PB-Esso Mobil Visa Debit Card

PERSONAL DATA OF PRINCIPAL CARDMEMBER

NRIC (New) 891027-02-5665
Name (as per NRIC/Passport) TEH ZHEN KIAT
Email Address 2kt3h89@gmail.com


RESIDENCE

Address 25,JLN DELIMA 10,
TAMAN INDAH,70400
SEREMBAN,NEGERI SEMBILAN.
State Negeri Sembilan
Post Code 70400

DECLARATION

DECLARATION BY NON-MALAYSIAN APPLICANT (TICK WHERE APPROPRIATE)
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No, I/my immediate family members do not hold have never held Senior Public Office
Yes, I/my immediate family members currently hold have held
Position held Date from to
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 and further to seek and obtain credit information related to my/our application from any source and by
any means as the Bank deems fit. I/We acknowledge that the Card may only be used subject to the Terms and Conditions of the PB Visa/PB
MasterCard 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.
I/We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as
those of the Supplementary Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own liabilities and
obligations. 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. I acknowledge that if my card application is approved, the yearly Annual Fee payable on the Card shall be waived provided my Card
Account is maintained to the satisfaction of the Bank, my Card Account shall remain active for the duration of this period and there is no change in
my credit standing as made known to the Bank. The Bank shall be entitled to review my Card Account at its sole discretion and withdraw this
privilege in the event that any of the above conditions have not been fulfilled upon which the Annual Fee shall become payable.
BANKING AND FINANCIAL INSTITUTIONS ACT 1989 (BAFIA) AND BNM GUIDELINES ON PRODUCT TRANSPARENCY AND DISCLOSURE
PERSONAL INFORMATION
I/We understand that the Bank would like to keep me/us informed of important information, announcements and news about the products and
services including promotional offers and marketing material of the Bank and its Affiliates*. Should I/we agree to be informed, my/our personal
information in the Bank's records will be made available to the Bank and its Affiliates for this purpose and as stated in the Bank's Privacy Policy.
My/Our preference is indicated below:
Yes, I/we would like to receive and be informed of the product and services including promotional offers and marketing material of the Bank and
its Affiliates and I/we make available my/our personal information (excluding information relating to my affairs or account) in the Bank's records to
the Bank and its Affiliates for this purpose and as stated in the Bank's Privacy Policy.
No, I/we do not want to receive and be informed of the product and services including promotional offers and marketing material of the Bank and
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its Affiliates.
I/We understand that I/we am/are entitled to obtain access to and to request correction of any personal information held by the Bank and that I/we
can inform the Bank to cease using my/our personal information for the purposes above and that such request can be made in writing to the Bank
at my/our account holding branch or by sending it to Customer Service Department, 13th Floor, Menara Public Bank, 146 Jalan Ampang, 50450
Kuala Lumpur.
*I/We understand that for details of the Bank's Affiliates, the collection, use, storage, sharing and maintaining the integrity of my/our information,
I/we can refer to the Bank's Privacy Policy at www.PbeBank.com. or obtain a copy from the Bank's branches.


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


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Parent / Guardian Declaration & Signature


Please sign here with dark black ink only.
Signature must not exceed box boundaries.
SIGNATURE: PARENT'S / GUARDIAN'S

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 and
Work Permit for Non-Malaysians; and
* Photostat copy of your Work Permit/Student Pass (for Non-
Malaysian only).
* Photostat copy of your Parent's/Guardian's NRIC (both sides)
or Passport and Work Permit for Non-Malaysian
Parent/Guardian (Applicable for applicant between 12 and 18
years old).

Note:
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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