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  • Forms-Credit Card Debit Authorisation

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    Ammar Dun
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    Forms-Credit_card_debit_Authorisation

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    9 views2 pages

    Forms-Credit Card Debit Authorisation

    Uploaded by

    Ammar Dun

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 2
    Fg tre ee Tereeosee Gown) F/O. WF alcove 07 0 Tei as beomsceseniclane ‘CREDIT CARD DEBIT AUTHORISATION FORM BORANG KEBENARAN DEBIT KAD KREDIT {nereby request.and authorize Takafullkttss Berhad to charge and to debit my credt cre acoaunt ta pay the conriution forthe fotowing “Takatul certicate(s) os stated below in accordance to the respective convibuton schedules (where applicable), ‘Saya dengen ini ernahon dan member kebenaran kepeda Tokafu! Khlas Berhacl mengenakan caj den mendebitken akaun kad ket saya untuk pembayaran bagi sumbangen sil Takefulsoperi yang dinyatakan dl bawah berdaserkan kepada jumlah sumbangad yang berkallan (Gika borkonan). NRIC No. (Now : RIC No. (O16) No. KP (Bary) i ‘No. KP (Lama) House Ta. No. : Offe2 Tel No ‘No. Tel Rua No, Tek Pojabat Mobile No. ‘Type of Credit Card ‘No, Tol. Bim . lenis Kad Krect [visa MastER Issuing Bank Bark Pengeliar ait No. ic ; . Card Expiry Date Z No. Kael Tarik Luput Kad NOTE! NOTA: 1) Please fit in either Part B ot Pert for Taka product ia is! Bahegian 8 afaw Bahaglan C untuk pera produ Takaf 2) Direct Debit Authorsalion wi take effect on next due date‘ nearest due date within grace period! Kabenaran Debit Terus akan erkuatkuasa pace frth sumbangan berkulnya atau pada lari surnbangan terdekat dalam tempon tengyeng. 8) For Takaful Generel, please filin PartB oniy/ Bag! Takaful Am, sla ‘sken Bahaglan B saheja, ‘Pave Violet: Gein Beeb vibe olongan Sas Satan ProductiCiass of Takatul/Produktlanis Takata \Vebicie Detas/ Butran Kenderaan: ‘Cover NotelCerlifcate/Propasat No. / No. Note Linduno./SiCadangan Conirbation Amaunt Jamia Sumbangan (RM) ie Particulars of contribution paymet instruction Buti bub arahah bayaren caruman. Rataioep a ee a enieate No. Narioc Cetfeata Omer! Partspant | Card sider! | Conon Amoust No. Sit ‘Name Pemegeng Sit/Pasarta | Habungan Dango | JamiahGarumon (Ru) \pemesang Kad Kec J We have read and tly understand tha notes overleaf and the Terms and Condons attached, 1/ We agree tet this authorisation i {governed by notes overleaf and Temis and Condivons attached, / Seya / Kam eleh membaca dan memaham sepenuiiys nia disabelah ddan syorat-syeral yang

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