Diners Club Malaysia

The Annual Fee

RM80 Entrance Fee-WAIVED;
Basic: RM35 Annual Fee - 2 Years FREE
Supplementary: RM15 Annual Fee - 2 Years FREE

Please complete ALL details & enclose a photocopy of your : -

	I/C (front & back) for Basic and/or Supplementary Card applicant
	Credit / Charge Card (front); OR
	Latest salary slip; and
	Additional documents as may be required during card processing.

THE DINERS CLUB INTERNATIONAL - DÉLIFRANCE COBRAND CARD APPLICATION FORM

YES! I wish to apply for THE DINERS CLUB INTERNATIONAL - DÉLIFRANCE COBRAND CARD

Source Code:

Full Name As In IC/Passport:

(please underline Surname)

Date Of Birth:

Sex:

Nationality:

Marital Status:

Old IC/Passport No.:

New IC No.:

Race:

Chinese Indian
Malay Others:

Status:

Bumiputra
Non-Bumiputra

Local Home Address:

Postcode:

Home Phone No.:

Handphone No.:

Years There :

	Own Property		Rented
	Mortgaged		Parents'/Relatives'

Permanent Home Address:

Postcode:

Permanent Home Phone No.:

Email:

Academic Qualifications :

No.Of Dependants :

Mother's Maiden Name:

Primary School :

Please Send My Billing Statement To:

My Home

My Office

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)

MY FAMILY
Spouse's Full Name As In IC/Passport :	(please underline Surname)
Date Of Birth:
Old IC/Passport No.:
New IC/Passport No.:
Hand Phone No.:
Office Phone No.:	ext.:

Name Of Closest Relatives/Friend Not Living With Me:

Relationship:

Home Phone No.:

Office Phone No.:

ext.:

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.:
I have never held a Diners Club Card before
My Previous Card Account No. :
Please emboss my name on my Card as follows (maximum 25 spaces, to include initials of full name as well)

SUPPLEMENTARY CARD
Please approve a Supplementary Card to the following person (above 18 years of age)
Full Name As In IC/Passport:	(please underline Surname)
Address:
Postcode:
Home Phone No.:
Hand Phone No.:
Date of Birth:
Sex:
Relationship:
Nationality:
Old IC/Passport No.:
New IC No.:
Race:	Chinese Indian Malay Others:

Status:	Bumiputra Non-Bumiputra
Name Of Employer:
Office Phone No.:	ext.:
Office Address:
Postcode:
Hand Phone No.:
Position Held:
Gross Annual Income:	RM
Please emboss my name on my Card as follows (maximum 25 spaces, to include initials of full name as well)

By signing below, I/we hereby reqest :-

Diners Club(Malaysia) Sdn Bhd (Diners) to issue a Diners Club International-Délifrance Card(DC-DFM Card) to me for my/our use upon the Terms and Conditions which accompany the DC-DFM Card(s) and any susbsequent amendments thereto; and

Délifrance (Malaysia) Sdn Bhd (DFM) to grant me/us Délifrance Membership based on Diners Club-Cobrand Card Rebate Loyalty Program Terms & Conditions (RLP Terms)

I/we hereby:-

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;

Declare that I am/we are not undischarged bankrupt(s) and have no pending Creditor’s Petition(s) against me/us;

Undertake to pay all sums charged to the DC-DFM Card(s) and to be jointly and severally liable for each other for the same;

Agree to be bound by the Terms and Conditions of the DC-DFM Card and the RLP Terms unless I/we return to you the DC-DFM Card cut into halves;

Agree that the use of the Délifrance Viva Ringgit Rebate earned is subject to the RLP Terms;

Agree that the use of Délifrance Viva Value Voucher(s) is subject to DFM’s Voucher Terms and Conditions;

Agree that in the event of any inconsistency and/or conflict between the Terms and Conditions of the DC-DFM Card and the RLP Terms, the terms and conditions of the Card shall prevail over the RLP Terms to the extent of the inconsistency and/or conflict and all the other Terms and Conditions of the DC-DFM Card as well as all the other RLP Terms shall remain valid and binding on me/us;

10.

Request that my/our DFM Membership annual fees (if any) to be billed to the DC-DFM Card under the Diners Club- DFM Autobilling System and agree to be bound by the terms and conditions of the System.

11.

Agree that Diners reserves the right to decline this application or withdraw, cancel or terminate my DC-DFM Card membership at any time without assigning any reasons thereto;

12.

Agree that Delifrance reserves the right to cancel or terminate my Delifrance Membership at any time without assigning any reasons thereto;

13.

Declare that the above information given is true and correct.


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

Basic Card No:
Supplementary Card No:


Card Terms & Conditions \| Credit Card Terms & Conditions @ Copyrights by Diners Club (Malaysia) Sdn Bhd (3908-K). All rights reserved.