Koperasi Gemilang Malaysia Berhad

Block C-5, SunwayPJ51A, Jalan SS 9a/19,

47300 Petaling Jaya, Selangor Darul Ehsan.
03-76651961 | www.kgmb.com.my | support@kgmb.com.my

To:
Accounts Department
Koperasi Gemilang Malaysia Berhad
Block C-5, SunwayPJ51A,
Jalan SS9a/19, SS9a,
47300 Petaling Jaya,4
Selangor Darul Ehsan
03-76651961
www.kgmb.com.my

AUTO DEBIT FACILITY CONSENT FORM

To be filled by Members

A. Auto Debit Facility Information

I, _____________________________________________________________________________with NRIC number

_____________________________________ hereby authorize Koperasi Gemilang Malaysia Berhad to
debit from my Debit/Credit Card for the monthly subscription payment as detailed below:

- Payment Cycle : Monthly

- Debit Date : (1-13 ) / (15-28) of every month.
- Card Type : Debit Card / Credit Card
- Account Holder's Name : ________________________________________________
- Debit / Credit Card No : ________________________________________________
- Bank Issuer : ________________________________________________
- Email Address : ________________________________________________
- Mobile No : ________________________________________________
- KGMB Membership No : ________________________________________________

Attention: Please contact your bank by calling the number provided behind your Debit/Credit card
and request the bank to Activate 2D Payment system with immediate effect.

Official Use Only

B. Monthly Contribution Details

- Subscription (RM) : __________________________________________
- Share Capital (RM) : __________________________________________
- Special Saving Scheme (RM) : __________________________________________
- Loan (_________________________) (RM) : __________________________________________

- Total Contribution (RM) :

C. Terms & Condition
I understand and agree to the following terms and conditions:

1. I authorize Koperasi Gemilang Malaysia Berhad to initiate monthly debit entries

from my specified Debit/Credit Card for the above said Total contribution from
Section B

2. This authorization is valid until I provide written notice to cancel or modify it.

3. I will ensure that there are sufficient funds in my bank account to cover the
subscription payment on the specified debit date range.

4. In case of insufficient funds or any other issues related to the payment, I will be
solely responsible for any fees, charges, or penalties incurred.

5. I have the right to request a cancellation or modification of this authorization by

providing written notice to Koperasi Gemilang Malaysia Berhad at least 25 days
prior to the next debit date.

6. I acknowledge that Koperasi Gemilang Malaysia Berhad will keep my bank account
information confidential and will use it solely for the purpose of processing the
above said Total monthly contribution payment.

By signing below, I confirm that I have read, understood, and agreed to the terms outlined
in this Auto Debit Consent Form.

Member’s signature : ____________________________________

Date : ____________________________________

Please return this signed form to Koperasi Gemilang Malaysia Berhad or send a scanned
copy to accounts@Kgmb.com.my

Thank you
Koperasi Gemilang Malaysia Berhad

We acknowledge the receipt of your Auto Debit Facility Form and will process it
accordingly. Thank you for choosing our services.

__________________________________________ __________________________________________
S. Kajaintharan A/L P Sithambaram Dr. Devaraju Joseph
Secretary Treasurer
Koperasi Gemilang Malaysia Berhad Koperasi Gemilang Malaysia Berhad

Date: Date: