Cen B EEA)
@2 visa
Borang Permohonan KAD-i BANK ISLAM / BANK ISLAM CARD-i Application Form
Sa lengkaptan den hartarkan barang ii besetadokune-dokamen yang dperskan
(dak akan dkembaikan) ke: / Please camolte and send this frm and documents
required non-reternab) to:
Pusat Kad Bank islam, Aas 6, ma Bank eam, Jalan Durgun, Sulit Damansara,
£0400 Kuala Lumpur atau cusjuigicauangan Bank elem yang berdkatan/ Or viet
‘eo nearest Sank lam aren
oD suMBen / SOURCE ODE OoOOboo
Kod Cawangan CSA/ Branch /OSA Code OOO
Paks /Ked Pakage Cole YW oDpoU
WWsiat/Kodejen/sattio/AgetGose |]
eee
denis tad / Card Type Pe buna jnimam/ Mastercard Visa
Pat ‘vas 009 oO
fas! ott e000 oo
sik asi azo oo
ELAYAKANUNUR / AGE REQUIREMENT
Ferrohon Kai Utara mest berumur 21 tan ke ata dan pemobon Kad Tambatan
‘mectleh beramar 18 tahun be sas. / Principal Card Apalcant mst be 21 years and atowe
and Suplreniany Card pica must be 18,yeasard abe.
BUTIRAN PERIBADI / PERSONAL DETA/
[Dlenanr ar (evan aca [Joa ms
(Clann eve
(Ginryoakn’ Pease pe)
aia eer Jeti tab] porn ee
ana neh Kad een Ps Nee as IPs
etran / Toe
ama ana terra pata Kad (iak melt 19 hand)
Name to anrearon Cord nc more than 19churactes)
CoOoSoooo0Cb000000303
Cltireroee Com vee Cen
No KP (Baru / NRC No. ow)
000000 - O00 - 0000
wieum ewe COOUIIL0
vorepot/Pesotme CIO OOONUOU00
Borgen Roce
Stas Pekawinan rt Saas
[Lasiane:snoe —(_] tetarin aries
(Cesreera overced F] ea wionea
DiTanggungan/ No.of Dependarts —_Kewarganegaraan /Nationalty
Tat ean seo Lovt
Clneningan’ seeimcay [] sw certente [pa Optoma
(Cliezan oreo [taansorama tasers [7] 01 cocoate
‘anax Fura (la angan wnekan alana war rege alu Pet Swat Feat Ps) /|
Permanent Ades (eased no provide averse or PO. Box Aes)
Poss / Pastoave
[ego Meneta Years There.
No. Tol Rumah / Heme To.
No. Tol Bint Handphone No.
Emel/ mal,
03-26 900 900
www.bankislam.com.my
Neget / State
[DOKUMEN PENTING YANG DPERLUKAN //MPORTANT DOCUMENTS REQUIRED
Unik mamudean prprsesan, sla setakan:/T expe processing please ends
17 Salnan ad pengsnaian (open dan bolstan clan paspot unt pomaton Kad
‘same den Frnohan Ka Tembahan ka ata). Copy o FIC eth sites) / passport for
Prins and Seplemertary Car apoicans (teptcatie)
Salman penyata ga 9 balan yang tek atu. / Copy fetes months’ pay sips
1 Salman bong EA tas penyale KS ala Copy ites! fm or EF staenen cc
7 Salnan torang 9/24/49 atau sainan Syl Pendafaran Pemigaan dan slnan pena
‘ark bla rk pk bekera sedi dan Boran 8 derganbuktpembayara cuka.
1 Copy of form 9/24/69 or Business Registration Cerficate and 6 mants' bank
statement sft empoyed wih te lates 8 For en tax payment recent.
‘oluren tamtahan munakin dnina serasa pirpenssan,Ketluan tera kepada
Denia kre leh Bank dan Bank bertak unk mendiak pemohanan tena sarang
‘sar. Unk pemohaan yang tdak teriva,cokumen yang disertkan fdek akan
(Siembalkan éan alan dnusnatkan. / Addons documents mye requested cing
precessing. Approvals sutetto te cet vauzton ofthe Bank ard he ark as eight
oto see anyresson fr dig. The supporting diamant nsveest apoiation
wil be destroyed andnotretmedto customer.
Penoton yang tak menpuny bull perdapaan, tapi menepat Kelayakan mur
‘minimum, Skehenial mensepstizn sejumih amaun ke dam Aan Pera Bias,
yang menyama dengan jamin Had Penbiayzan Kad yang dipoton, Anaun ‘rebut
hendekeh sino eam akan seariang rasa, ean] Kad: Ban sam tesehut a
The Aoplcant who fs unable f provide any income evence. ut mets te minum ape
‘ecuimentisrequired 'o cepasting Genera ImesmentAccont. n amcunequhalent
{a thecad fnanchg lit anpted The copst inthe General lnestnent Accaut-ishll be
maintained fr as ong asthe Bark lan Cartel act.
Panama suat-neayrat/Choce obilng adress
Aumay/tone ———[_] abit Oe
Fo Rodan estes Tie
Ma er Ova outage One by Pats
Sts /Meragnd [7] Svar
Main sak /Enpoye ed
Lanner (Sia nyaatan Peas se)
‘lamat Tet (a fargangundkan aaa ua negara Pet Surat Plat Ps)
Peamanent Adress peese dot prove oversea or PO, Box Adress)
Poskod/Postoode ‘Negeri /State
No Tel. /Te Mo,
"Nama bw / Maths Wade ame
(Uni adalah untuk pergesahan jca ipeiukan Tis Is Tor security werleation
wen requir
BBUTIRAN PEKERJAAN/PERNIAGAAN / DETAILS OF EMPLOYMENT/BUSINESS
Naa Syaska/ Mame of Company.
‘Aamat (ia angen guekan alana! ar nger atau Pet Surat Pjabat Pos) / Permanent
Actress pvaso dot provids ovrsocs er PO. Bor Ares)
Foskes /Fetode
Jian Destin
Ne T/T ho Santingan/ Extra
Tea abet ean Bt net not er
eset / Tipe of npoyment
een emaront—(] Kt oneact Someta Tenay
JmisPeniagann/ treo Bsiess
Nisha ermagen Buses Csseaten
[Ly sect Sot Papin [Dang / Parner
Sevan Bata Prva ted
eran / Government
Lani Others
BANKCSLAM
Negeri StePendapatan Tenunan / Permiagaan (AM) / Annual / Business income (RW)
Lain-lin Pendapatan (RM) / Ofer Income (A).
Bilangan Kad Krodit/ Kad Cj yang cms /
Number of Credit Cards)! Charge Car held
POR
(lbu bapa, adik-beradik atau saudara-mera yang tidak tinggal sorumah
‘dengan anda/ Parents, siblings or relatives not living with you)
Nama/ Name
Petaian/ Relish.
No.Tel. Rumah / Home Tl Ho.
No.Tel Pejebat / Ofc Te. No,
No.Te. Bimoit/ Hangame No.
RUTIRAN PASANGAN / DETAILS OF SPOUSE
Nama/ Name
No KP (aru) / MAIC No. (Mew)
000000 - 00-0000
No. KP (lama) / eve. r9 JO OO000
Wo. Pesport/RassportNe. TO OO0O00
Nana Sark / Name of Compay.
Jawatan/ Designation,
Mo.Te Peebat fice Tel Mo.
Wo.Te Bmoit/Harapnone Wo.
‘etran Tite [] Encik Mr] Puan /Masam [_] cies
(Cusinstain otters (Sta nyetakan/ Pease spect)
antina / Gender [) Lelaki ‘Mate [—] Peremouan / Female
‘ewan ag
Nama yang trtera pada Kad (idak melebihi 19 huruf)/
‘Name to appear on Gerd (not move than 19 characters)
OOOOOOOOOooo0oO00e000
“ahi! Dai of Birth
(Da oto (eaten aontn (tahun Yar
Wo. KP (lamay/ ewe. ory {JL OOOO
Wo. KE Ear) / NIC No. Men
OOOO - 00-0000
MoT Te No.
Wo.Te, emo Harapnone na
Pertaian Dengan Ani Kad ama / Relationship To Principal Cardmemder
ira bu (Urtuk Tuan Pengesshen | Nother’ Maiden Name Fer Vrication Purpose
‘a rocTren greg sepa ara
‘ee cgsenery Sotto eae ab Re rot
Tadatangan Pemohon Kad Tabehan/ Signature of Stoplementary Card Aolicant
Tank Date:
Eimub cnt aay Eure
1. PENGAKUAN AHL! KAD UTAMA /
‘DECLARATION BY PRINCIPAL CARDMEMBER
Pngaluan dri Aili Kad Utama berhubung dengan gris panduan Bank Negara
Nalaysia bagi urusniana dan pendedahan kiedt dengen pihak berkaitan/
‘Declaration by Principal Cardmember in connection with Bank Negara Malaysia
idelnes on credit ransactons and exposures wih connected parties.
‘Saya aalah secrang kaktangan Bank sam. / Jama staf of Bank ian,
Pada pengetahuan saya, saudara terdkat saya seperti di bawah adalah
‘merupakaa kaktangan Bank san atau merupakanperiamin say. To fhe best
‘of my knowledge, my clese reat as mentioned bel f employed by Bank
‘sam or is acing as my guarantor
Maklumat saudera terdekat yang merupakan keki‘angan Bank Islam. /
Fartculars of my clase relative employed by Bank islam.
Nama! hae
No. KP (Bary / NAIC. er
Poel "O10 - Oooo
Pertalian TRletionsnip
Berindak sebagai Penjamin/ Acting as Guarantor
(Sle nyataken YA atau TIOAK/ Please indicate YES or NO)
2 PENGAKUAN MAKLUMAT DECLARATION OF FORMATION
“saya meagesatkan tahawa maka yang saya berkan in fash Desay, saih don
leegean Says dengan I momen kash hapada Bank leary Malayia Berhad ("Bark
Ian) uluk rendaratian ara-apa maklimat tentang saya cada majkan sya
maranara situs ceveoa, Kets Pew Lenten Yas Daan Neg dan
fa nara cumbryang itin seiaGh Sk sla. Soya up nengesadkn
bance bs bapa dana anak er, ak beraak saya én pasangan masng mein
Duka raktargan Bank sam Mla} Baad canal ak sharkaty, Saye 2a
fertckl fepade Terme rat Sjraturuk Peblaygan tat Bark am
(TermaTera éan Sparc Syarat Kad") don sega pindan-pndaan ke atasnya pac
‘maz ear along soar dengan pongluran atau dorgquncan Ka ka) Bank aan.
Soya stouseya bese banawa Aa Ca Usa sdaah bertanggunjanad tad
sua fabian blgasi Abi Kad Utama seta Aah) ad Tambafan. Wala
bgeimanepun Ahi-al) Xa Temtahan Nanya akan betarggundiawabtethadag lit
din oblgasinya seri. Saye juga beseuj bahava Bank ism memgunyai hax untuk
Melus au mendlak manz-rana femotoran saya ‘apa member apa-apa sad
Saye far bana Kao kas) Bark sam skate eral Macrae Bank sam
TertelucRepade mane-rana pamoatlancengan nts aval dan Gkembalan stl