Borang Permohonan Perkhidmatan Pinjaman Sewa Beli / Lending Service Request Form Hire Purchase *Effective 1 April 2015, 6% Government Service Tax is applicable on all fees and charges.

*Ruang mandatori / Mandatory fields

Pemegang Akaun / Account Holder Name*

NRIC / Passport No.*

Nombor Akaun / Account No.* No. Kenderaan / Vehicle Registration No.*

No. Telefon / Contact No.*

Pihak Yang Diberi Kuasa / Authorised Person Pihak individu / entiti dibawah diberi kuasa untuk mengakui penerimaan item yang berikut. The individual /entity below is authorised to collect/acknowledge receipt of the following item(s) below. Nama / Name

NRIC /Passport No.

Perkhidmatan Untuk / Service Request For:

Kad Pendaftaran (No. Siri) Saya/kami bersetuju untuk melindungi Bank daripada semua kerugian yang mungkin dihadapi oleh Bank disebabkan permintaan ini. I/we agree to indemnify the bank against any losses arising from our request herein.

Registration Card (Serial no.)

e-Batal Salinan Perjanjian Pinjaman Sewa Beli/Sewa Beli-I/Kad Pendaftaran Discharge of Ownership Photocopy of HP / HP-I Agreement/ Registration Card

Jumlah Baki Pinjaman Sewa Beli Lain-lain / Others (Sila Nyatakan / Pls. Specify) Settlement Amount for HP Account

Penyata Akaun (Yuran RM20 bagi setiap tempoh penyata) Dari / From: Sehingga / To: Statement of Account (fee of RM20 per statement cycle)

Untuk Kegunaan / For The Purpose(S) Of:

Pembaharuan Cukai Jalan Tuntutan Insurans / Takaful Renewal of Road Tax Insurance / Takaful Claims

Pemeriksaan JPJ Akaun Kontra JPJ Inspection Contra Account

Simpanan Safekeeping

Lain-lain / Others (Sila Nyatakan / Pls. Specify)

Kaedah Penghantaran / Mode Of Delivery

Sila pilih kaedah penghantaran bagi perkhidmatan yang dipohon / Please choose your preferred mode of collection for the selected service request(s): * Dikutip di Cawangan / Hantar ke alamat surat menyurat / Collect at branch: (Sila nyatakan cawangan / Please specify which branch) Send to my correspondence address

Tandatangan Pemegang Akaun / Account Holder Signature Pihak Yang Diberi Kuasa / Authorised Signatory*

(Jika ini adalah akaun bukan persendirian, cop syarikat perlu disediakan. Untuk Perkongsian dan Syarikat Sendirian Berhad, kebenaran daripada salah seorang rakan kongsi dan kelulusan daripada salah seorang pengarah perlu dilampirkan. / If this is a non-individual account, companys stamp is required. For partnership and private limited company, consent from one of the partners, and authorisation form any one of the directors is required.)

Tarikh / Date*

Untuk Kegunaan Bank sahaja / For Banks Use only: Semakan biometrik diperiksa / Biometric check done: Receiving Branch Verified By Attended By Updated By Checked By

Passed Failed

Name & Stamp

Date & Time

Date & Time

Date & Time