PB Card Online

Application Customer
Copy

Reference Number : OA0718133565

CARD SELECTION

Card Type PB Visa Electron (D1YWWB1204)

PERSONAL DATA OF PRINCIPAL CARDMEMBER

NRIC (Old) A1234997

NRIC (New) 681226-02-5443
Name (as per NRIC/Passport) Azhar Bin Ramli
Email Address artramle@yahoo.com.my

RESIDENCE

Address Batu 19,

Jalan Kuala Nerang

State Kedah
Post Code 06300

DECLARATION

DECLARATION BY NON-MALAYSIAN APPLICANT (TICK WHERE APPROPRIATE)

No, I/my immediate family have never held Senior Public

do not hold
members Office
Yes, I/my immediate family currently
have held
members hold

Date
Position to
held

I/We confirm that all the above information is true and complete and authorise the
Bank to verify from whatever sources the Bank may consider appropriate including
Inland Revenue Board. I/We acknowledge that the Card may only be used subject to
the Terms and Conditions of the PB Visa Cardmember Agreement and agree to be
bound by the Terms and Conditions of the Card. I/We agree to pay the prevailing
annual fees upon approval and shall accept joint and several liability for all charges
on my/our Card Account(s) with the Bank. The Bank shall reserve the absolute right to
approve or reject my/our application as the Bank deems fit without assigning any
reason.

I/We irrevocably consent to and authorise the Bank to disclose to Bank Negara
Malaysia, any authority/body having jurisdiction over the Bank, any
guarantor(s)/security parties, and/or its lawyers or any other debt collection agent,
companies which are related to the Bank by virtue of Section 6 of the Companies Act
1965 at any time and without notice or liability any information relating to my/our
affairs, banking accounts or conduct thereof (including my/our credit standing) to
such extent and for such purposes as the Bank may in its absolute discretion deems
necessary or expedient.

Please sign here with dark black ink only.

Signature must not exceed box boundaries.

SIGNATURE: PRINCIPAL CARD APPLICANT

Thank you for applying via the

PB Card Online Application. To
expedite processing, please
remember to enclose the signed
PB Card Online Application
Customer Copy together with the
following documents for
submission to us:

Documents to be submitted:

* Photostat copy of your NRIC

(both sides) or Passport for Non-
Malaysians; and
* Photostat copy of you Work
Permit/Student Pass (for Non-
Malaysian only).

Note:
1)Documents submitted are non
returnable.
2)If the above required
documents do not reach PB
Card Services within 30 days
from the date the PB Card
Online Application Form is
submitted, your application
will be cancelled
automatically.

Address
PB Card Services
10th Floor, Menara Public
Bank,
146 Jalan Ampang,
P.O. Box 11722,
50754 Kuala Lumpur
Tel. No. : 03-2176 8000
Fax No. : 03-2163 9400