Billion Bridge Marketing (002219666-M)

No 36-3-2, Cheras Business Centre

Jalan 2/101C Batu 5 Taman Cheras
56100 Kuala Lumpur.

CREDIT CARD FIXED REPAYMENT SCHEME (FRS) ACCEPTANCE FORM

YOUR ACCEPTANCE
Please enclose photocopy of I.C (Front & Back)
Name: CHUI CHIN KONG

Credit Card(s) Account Number:

I.C./Passport/Army/Police No: (new) 830121-06-5701

Mother's Maiden Name (for security verification):

(old)

---

LEE

Billing Address: NO. 206, TAMAN BUKIT KOMAN 27600 RAUB PAHANG

Name of Company/Employer: SJKC PADANG TENGKU

Occupation: HEADMASTER
Current Salary: RM 3896.24
Other Income:
Contact No(s): (Home)
(Office)
williamchui83@gmail.com
Email address:

NIL

(H/P)

0129846080

DECLARATION
I hereby agree to convert all my (and my supplementary) current credit card(s) owing to a Fixed Repayment Scheme account.I agree to be liable for all
outstanding balances in my Fixed Repayment Scheme account.I hereby confirm and declare that all information provided by me is complete, true and correct
and that I authorize the Bank to verify and information provided and to obtain from any sources including Inland Revenue as the Bank considers appropriate
any information, which the Bank may require. The Bank may at its sole and absolute discretion approves or reject my application. I agree that by signing, I
agree to be bound by and to comply with all terms and conditions of the Bank card member agreement(s) and conditions imposed by the Bank from time to
time for credit facilities and all amendments there to. I understand that the Bank will cancel the existing personal loan facility and will not grant new credit
card/personal loan facility to me. I hereby confirm that my immediate familymembers i.e parents/spouse/children are not employees of the Bank. I
irrevocably and unconditionally agree, authorize and permit the Bank to disclose or release to Bank Negara Malaysia, Cagamas Berhad, the credit bureau or
central bureau established by Bank Negara Malaysia and such other authorities pursuant to any applicable law, regulations or directive (wether having the
force of law or otherwise) or any party as the Bank shall deem fit, any information with respect to me for any purpose including but not limited to the purpose
of assessing my / our credit worthiness. I hereby confirm that no further permission or consent from me is necessary or required in relation to all of the above
disclosures and this declaration shall constitute the consent required pursuant to section 99(1)(a) of the Banking and Financial Institutions Act 1989 and any
other contractual consent for such disclosures. I shall not dispute the contents of the faxed copy received by the Bank which shall be deemed as the original
application and I shall produce the original application to the Bank upon request. I agree to abide by Anti- Money laudering laws of Malaysia. In the event I fail
to comply to the terms and conditions of the Fixed Repayment Scheme including default in the monthly payments that is required to setle under the Fixed
Repayment Scheme, the said Scheme shall be deemed as cancelled and the wole outstanding sum (inclusive of interest) under the credit card facility shall
immediately be payable to the Bank and the Bank shall have the full rights to charge me further interest based on the rate under the Credit Card facility or at
any rate at your sole discretion
For principal card applicant only: I agree to be liable for all outstanding balance in my Fixed Repayment Scheme account.

_________________________________________

Signature Of FRS Customer

Date: 03.03.2014

Supporting Information
Payment Method:
Office Address:

Last Use:
Account other than credit card (please list):

Auto Debit:
Insurance:
Full Name of Spouse:
Emergency Contact Name:
Emergency Contact Relationship:

(H/P)

Applicant's Signature

CHUI CHIN KONG

Applicant's Name :
NRIC
: 830121-06-5701

H/P No
Date

:
:

For Office Use Only

Remarks:

Received by
Name:
Date:

Agent
Name:
Date:

0129846080
03.03.2014