ROLIER GROLIER (MALAYSIA) SDN BHD co 1: 2750004) cence no. Ast 9647 ( x el 7, Plaza Fest Natio, 167, ba Tan Loe, 50000 Kast Lumper, Moly ‘ate 26867688 (20 Lies)» Fax 608 20705708 + Wobste wow. gre com.my How to enrol Fare ce a ee aos sa mice emma re I peer gm ce poe emer AutoPay Credit Card Enrolment Form tose vars ape aca vee tere sa a WELSON KuToRo cece chee $1916). 10:3 210). 13141619) 1 6 FT otra CMB BANE ae O15) 1210 New WRICNo. BiSioi6iais (ee SiO ee een eam cone mee oe 2 2 Pie se ome LL ! ean = i ey waa/masercarsmersamo Lol2ziz}ojsjilij{sisisislo Email Address We 0 Conn Grolier Monthly Installments Details of Grolier installments 1. contact (as) ee 2. Contract No, umber oftetaiments L214) montns reset an) SSID per rorah Please enrol me inthe AutoPay Service(s) as indicated above and charge the monthly instalments to my Visa / Master ardor the renewal or replacement Cards) sued, when it's going to due or overdue, unt the contracts uly pad Shauld you need assistance, please do not hesitate to call our Collection Department at 03-2688 1688 / 03-2688 1782 \ hereby give my consent to GROLIER (MALAYSIA) SON. BHO. under Osta Protection Act 2010 to se the personal data in this form to process my payment. (For more Information, please visit our website at worw.groler.asa.com or POP website at www. pdp gou.ny. In the event where the Autopay s rejected by the bank, the company reserve the ight to cance the Autopay mode of payment and transfer to our Authorised Collection agent or Recovery Agencies to asist in collecting the overdue payment by signing here, | certify that | have read and understood the terms and Conditions on this form. | agre to be bound by them ‘and agree that shal ony responsible for my own libilies and obligations. sa 1G 291% Cardholders Signature ate India * Indonesia © M: sia * Philippines * Singapore * Taiwan * Thailand