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HongLeong Bank
Hons Lonq Banl Berhad p7,!al
r-r Cek Jurubank
(BC)
rr Draf
(DD)
r-r Pindahan Berteleoraf
(TT)
r- GIRO Antara Bank
(lBG)
I I
Banker's cneque (eq L) oemina'oraft (DD)
I I
Tebgraphic Tranifer (TT)
l I
lnterbank GlRo (tBG)
Tarikh / Date :
S
lP*8,-*,-"-nP-lslamic
Bank
@-
BORANG KIRIMAN WANG
REMITTANCE APPLICATION FORM
BUTIR.BUTIR PEMOHON I PARTICULARS AF APPLICANT
Kadar
Rate
Matawang
Currencv
Amaun Matawang Asing
Foreiqn Currencv Amount
Nama
Name
No. KP
lD No.
Alamat
Address
RMAmaun I RMAmount RM
Komisen I Commission RM
No. Tel.
Tel. No.
BUTIR-BUTIR PENERIMAI PARTrcALARS AF BENEFICIARY
Cukai Setem I Stamp Duty RM
Nama
Name
Bayaran Kabel I Cost of Wre RM No. KP
lD No.
Alamat
Address
Negara I Country
Jumlah I Total RM
KAEDAH PEMBAYARAN I MODEOFPAYMENT
No. Tel-
Tel. No. f_l
Tunai/ Cash
[l
r.ro. cek I cheque No.:
BANK PENERIMAI BENEFICIARY'S BANK
Nama
Name
Sila tulis cek dibayar kepada "HLBB / HLISB untuk permohonan < Draf / Cek Jurubank / IBG
I Pindahan Bertelegraf >", dimana berkenaan. Please make your cheque payable to "HLBB /
HLISB for < Demand Draft / BC / IBG / OTT > application". whichever applicable.
fl
Mendebitkan Akaun saya / kami No. t Debit my / our account No.
No. Akaun Penerima
Beneficiary's NC No.
Alamat
Address
Negaral Country
BUTIRAN PEMBAYARAN I PAYMENT DETAILS
beperu yang olnyalaKan oan oloata(Katl ol aras saya / Karllr rlrrlltd d"ud Illcrrgciudr^drr urar i
Cek Jurubank anda dan melaksanakan Pemindahan Telegraf / GIRO Antara Bank bagi pihak
saya / kami tanpa risiko dan tanggungjawab kepada anda dan tertakluk kepada Terma dan
Syarat yang tercetak di muka sebelah.
As specified and detailed here I / we request you to issue your Demand Draft / Banker's
Cheque or effect Telegraphic Transfer / lnterbank GIRO on my / our behalf and without risk
and responsibility to yourselves and subject to the Terms and Conditions set fotlh on the
reverse hereof.
Tandatangan Pemohon I Applicant's Signature
No. Rujukan Pembayaran (No. Bil / lnvois)
Payment Ref. No. (Biil / lnvoice No.)
Keterangan Pembayaran
Payment Description
Lain-Lain Butir
Other Details
UNTUK AKTA KAWALAN PERTUKAMN WANG 1953 (Sila beri tujuan)
FOR EXCHANGE CONTROL ACT 1953 REQUIREMENT (Ptease'indicate reason)
f,
Pelancongan./ Iravel
f1
P endidikan / Ed u catio n
I
Keuntungan & Dividen /Prof,ts & Dividends
f-l
Perkhidmatan / Seruice btr- nyatakan / ptease specq
aFaedah
/ lnterest
I
Pengangkutan Barangan & lnsuran /Frelght & lnsurance
[-l
eenggalian Peketja / Remuneration For Employees
I
L"in-t"in U OtA ers bila nyatakan / please specify)
Kadar Khas Oleh I Special Rate By No. Kontrak I Contract No.
REM 9-2 (11/10)
Bulk Return Form P No. Signature Verified
lAttended
By Checked By Authorised By
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