Diners Club Malaysia

Upon renewal:
The Annual Fee is RM75 (Basic Card) & RM35 (Supplementary Card)

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

	I/C (front & back) for Basic 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.

YES! I wish to apply for the Diners Club - MAA Assurance International Cobrand Card.

Source Code:

Gift Code:

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:

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)

Autobill Insurance Premiums
Policy No:
Premium Amount:	RM
Payment Mode:	Monthly Quarterly Semi-annually Annually

By signing below, I/e hereby request:-

Diners Club (Malaysia) Sdn Bhd (“Diners”) to issue a Diners Club Card - MAA Assurance Cobrand Card (“the Card”) to me/us;

agree to accept and be bound by the said Terms and Conditions which accompany the Card/s, its renewal and replacement, and any other subsequent amendments thereto unless I/we return the Card/s cut into halves to Diners;

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 legal proceedings and/or executions against me/us;

agree to be liable for all sums charged to the card;

agree to be jointly and severally liable for each other for all sums charged to both the Basic and Supplementary Card;

agree that Diners reserves the right to approve or decline this application and/or withdrawn, cancel or terminate the Card/s at any time without assigning any reasons thereto;

request that my MAA insurance premiums to be billed under the Diners Club - MAA Autobilling service and agree to be bound by the terms and conditions of the service;

declare that all the above information given is true and correct;

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

Basic Card No:
Supplementary Card No:

For MAA Assurance Use Only

Verified by

Date


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