Kad Kredit-i Bank Islam
BORANG PEMBATALAN ARAHAN AUTO DEBIT / AUTO DEBIT CANCELLATION FORM MAKLUMAT AHLI KAD / INFORMATION OF CARDMEMBER Nama Ahli Kad / Cardmember’s Name
____________________________________________________________________________________________ No. Kad Pengenalan / NRIC No. : ___________________________ (Baru / New ) ___________________________ ( Lama / Old ) / Nombor Kad / Card Number Tarikh Luput Kad / Card Expiry Date B/M T/Y / B/M T/Y
PEMBATALAN ARAHAN AUTO DEBIT / AUTO DEBIT CANCELLATION DECLARATION Saya dengan ini membatalkan arahan pembayaran secara autodebit kerana / I hereby wish to cancel autodebit payment order due to : Membuat bayaran secara tunai / cek dan lain-lain / Paid by cash / cheque and etc. Lain – lain (sila nyatakan) / Others (please specify) : _____________________________________________________________ _____________________________________________________________
MAKLUMAT AKAUN BANK ISLAM / BANK ISLAM ACCOUNT DETAILS Berikut adalah butir-butir Akaun Bank Islam saya / Please find details of my Bank Islam Account as below : Nombor akaun / Account no. : ___________________________________________________________________________ Jenis akaun / Type of account :
Semasa / Current
Simpanan / Savings
Sila tandatangan di sini / Please sign here
Tandatangan Ahli Kad Utama / Signature of Principal Card Member Tarikh / Date : _______________________________________
UNTUK KEGUNAAN PEJABAT / FOR OFFICE USE Arahan / Instructions : ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Disediakan oleh / Prepared by Tarikh / Date : Pusat Kad Bank Islam Aras 24, Menara Bank Islam, No. 22 Jalan Perak, 50450 Kuala Lumpur Email :
[email protected] • Fax : 03-2726 7606
Disahkan oleh / Verified by Tarikh / Date :
Diluluskan oleh / Approved by Tarikh / Date :
