s Diners Club Malaysia
 
 

The Annual Fee
  • Basic: RM70
  • Supplementary: RM35 (FREE)
 
Please complete ALL details & enclose a photocopy of your :-
Photocopy of I.C (both sides) for Principal and/or Supplementary Card applicant
Passport for non-Malaysian;
Credit / Charge Card (front); OR
Latest salary slip; and
Additional documents as may be required during card processing.
 
 
The Diners Club - COSTAM Affinity Card Application Form
YES! I wish to apply for the Diners Club - COSTAM Affinity Card
Source Code:
K3
02
 17
My Personal Particulars
Full Name as in IC/Passport:
(please underline Surname)
Date of Birth:
Sex:
Nationality:
Race: Chinese Indian
Malay Others:
 
Status: Bumiputra
Non-Bumiputra
Marital Status:
New IC No.:
Old IC/Passport No.:
Local Home Address:
Postcode:
Home Phone No.:
Handphone No.:
Own Property Rented
Mortgaged Parents'/Relatives'
Permanent Home Address:
Postcode:
Email:
Mother's Maiden Name:
Primary School Name:
Please send my Billing Statement to: My Home My Office
My Family
Spouse's Full Name as in IC/Passport : (please underline Surname)
New
IC/Passport No.:
Hand Phone No.:
Name of Employer:
Office Phone No.: ext.:
Position Held:
My Emergency Contact
Name of Closest Relatives/Friend Not Living with me:
Relationship:
Home Phone No.:
Office Phone No.:
Hand Phone No.:
My Financial Particulars
I hold the following Credit/Charge Cards:
1. Name of Card:
A/C No.:
2. Name of Card:
A/C No.:
Please emboss my name on my Card as follows (maximum 23 spaces, to include initials of full name as well)
My Work
Name of Employer:
I am Self Employed Yes    No
Office Address:
Postcode:
Nature of Business:
Office Phone No.: ext.:
Position Held:
Year Joined: 19   20
Gross Annual Income:
 RM
(min. RM24,000/p.a)
SUPPLEMENTARY CARD
Please Approve A Supplementary Card To The Following Person (Above 18 Years Of Age)
 Please Submit :
Photocopy of I.C. (Both sides) or Passport non-for Malaysian.
Full Name as in IC/Passport:
(please underline Surname)
Date of Birth:
Sex:
Relationship:
Nationality:
Race: Chinese Indian
Malay Others:
 
Status: Bumiputra
Non-Bumiputra
New IC No.:
Old IC/Passport No.:
Local Home Address:
(if different from the Basic Cardmember)
Postcode:
Home Phone No.:
Hand Phone No.:
Name of Employer:
Office Phone No.: ext.:
Office Address:
Postcode:
Position Held:
Gross Annual Income: RM
Please emboss my name on my Card as follows (maximum 23 spaces, to include initials of full name as well)
Declaration
By signing below, I/We hereby request Diners Club (Malaysia) Sdn Bhd (Diners) to issue a Diners Club - COSTAM Card (The Card) to me/us for my/our use upon the Terms and Conditions which accompany the Card/s and any subsequent ammendments thereto. I/we hereby:
1.
 agree to be bound by the said Terms and Conditions as well as the Rules and Regulations of COSTAM (COSTAM Rules) unless I/we return to you the Card/s cut into halves;
2.
 agree that in the event of any inconsistencies and/or conflicts between the Terms and Conditions of the Card and the COSTAM Rules, the Terms and Conditions of the Card shall prevail over the COSTAM Rules to the extend of the inconsistencies and/or conflicts and that all the other Terms and Conditions of the Cards as well as all the other COSTAM Rules shall remain valid and binding on me/us;
3.
 undertake to pay all sums charged to the Card/s and to be jointly and severally liable for each other (i.e. between Basic and Supplementary Card Applicant) for the same;
4.
 declare that I am/we are not underdischarged bankrupt/s and have no pending Creditor's Petition against me/us;
5.
 declare that all the above information given is true and correct;
6.
 irrevocably give consent and authorise Diners to conduct credit checking on me/us from any credit reference agencies, authorities and any other sources and shall permit Diners to obtain, verify, exchange, disclose and release any information so obtained or possessed at any time and from time to time at Diners sole discretion to any party without further reference to me/us. I/we hereby acknowledge that Diners shall not be liable to me/us or any party at all times regarding any matters arising from this consent and authorization;
7.
 agree that Diners reserves the right to decline this application or withdraw, cancel or terminate my Card membership at any time without assigning any reasons thereto;
8.
 agree that should COSTAM for what ever reasons terminate my membership, my Card membership will automatically be terminated.
Send no money now. Upon approval, Diners Club will bill you for annual fees(if applicable), I/We have read this Membership Form, including it's Terms and Conditions listed above, and agree to its terms.
Signature of Basic Card Applicant Signature of Supplementary Card Applicant
Date: Date:
For more information, please call DINERS CLUB's Customer Service Personnel at : 03-2161 1055. Please complete this application form above and mail it together with the necessary documents to : DINERS CLUB (Malaysia) SDN BHD. (3908-k) P.O BOX 11095, 50990 KUALA LUMPUR

For security purposes, please DO NOT send account or confidential information via the Internet or e-mail as it will not be encrypted during transmission. For Malaysia Residents Only.
 
For Diners Club Use Only
APC1 APC2   R
Basic Card No:
Supplementary Card No:
 

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