Please complete the form using black ball point pen and BLOCK leers and numbers only. Sila lengkapkan borang dengan pena mata bulat dan huruf BESAR dan nombor sahaja. A. MAKLUMAT AKAUN PUSAT TANGGUNGJAWAB / MAKLUMAT KAD (Untuk kemaskini maklumat akaun sila lengkapkan seksyen A) (Untuk pusat tanggungjawab berganda, sila isikan borang berasingan) ACCOUNT INFORMATION (For Account information update, please complete section A) B. COST CENTRE/ CARD INFORMATION (For multiple cost centre, please fill up separate form) COST CENTRE NAME (Oponal) NAMA PUSAT TANGGUNGJAWAB (Tidak Wajib) COST CENTRE LIMIT(Oponal) HAD PUSAT TANGGUNGJAWAB (Tidak Wajib) (RM) Request Type (Please ck (√) one) Jenis Permohonan (Sila tanda (√) satu) Card Type (Please ck (√) one) Jenis Kad (Sila tanda (√) satu) Product Category (Can ck (√) more than one) Kategori Produk (Boleh tanda (√) lebih daripada satu) New Card Kad Baru Card Cancellaon Pembatalan Kad Card Replacement Pengganan Kad Card Limit Update Kemaskini Had Kad Card Acvaon Pengakfan Kad Change Product Penukaran Produk Standalone Persendirian Driver Pemandu Vehicle Kenderaan Subsidy Subsidi Fleet Manager Pengurus Kenderaan Single Transacon Limit Had Satu Transaksi Daily Card Limit Had Harian Kad Purchase Limit (To nearest RM value) Had Pembelian (RM) Monthly Card Limit Had Bulanan Kad Count Limit (Oponal) Had Kiraan (Tidak Wajib) Daily Transacon Limit Had Transaksi Harian Monthly Transacon Limit Had Transaksi Bulanan Petrol RON97 Petrol RON95 Diesel Lubricant Pelincir Kedai Mesra Name To Appear On Card (For New Card) or SmartPay Card Number (For Card Cancellaon, Card Replacement, Maintenance, Card Acvaon & Change Product) Nama Yang Akan Tertera Pada Kad (Untuk Kad Baru) atau Nombor Kad SmartPay (Untuk Pembatalan Kad, Pengganan Kad, Kemaskini, Pengakfan Kad & Penukaran Produk) Vehicle Registraon No. No. Pendaſtaran Kenderaan Postcode Poskod SmartPay Account No. No. Akaun SmartPay Individual/Company Name Nama Individu/ Syarikat Address (P.O Box Address NOT acceptable) Alamat (Alamat Pe Surat Pejabat Pos TIDAK diterima) State Negeri Email Emel Contact Name Nama untuk Dihubungi City Bandar Tel. No. No. Telefon Mobile No. No. Telefon Bimbit Fax No. No. Faks SMARTPAY MAINTENANCE FORM / BORANG KEMASKINI SMARTPAY PETRONAS Customer Experience Centre Suite A-1-1, Hampshire Place Office, 157 Hampshire No.1, Jalan Mayang Sari 50450 Kuala Lumpur / Pusat Pengalaman Pelanggan PETRONAS TEL 1-300-88-8282 FAX 1-300-22-3333
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Please complete the form using black ball point pen and BLOCK letters and numbers only.Sila lengkapkan borang dengan pena mata bulat dan huruf BESAR dan nombor sahaja.
A. MAKLUMAT AKAUN
PUSAT TANGGUNGJAWAB / MAKLUMAT KAD
(Untuk kemaskini maklumat akaun sila lengkapkan seksyen A)
(Untuk pusat tanggungjawab berganda, sila isikan borang berasingan)
ACCOUNT INFORMATION (For Account information update, please complete section A)
B. COST CENTRE/ CARD INFORMATION (For multiple cost centre, please fill up separate form)
COST CENTRE NAME (Optional)NAMA PUSAT TANGGUNGJAWAB (Tidak Wajib)
COST CENTRE LIMIT(Optional)HAD PUSAT TANGGUNGJAWAB (Tidak Wajib)
(RM)
Request Type (Please tick (√) one)
Jenis Permohonan (Sila tanda (√) satu)
Card Type (Please tick (√) one)
Jenis Kad (Sila tanda (√) satu)
Product Category (Can tick (√) more than one)
Kategori Produk (Boleh tanda (√) lebih daripada satu)
Individual/Company NameNama Individu/ Syarikat Address(P.O Box Address NOT acceptable)Alamat(Alamat Peti Surat Pejabat PosTIDAK diterima)
StateNegeri
EmailEmel
Contact NameNama untuk Dihubungi
CityBandar
Tel. No.No. Telefon
Mobile No.No. Telefon Bimbit
Fax No.No. Faks
SMARTPAY MAINTENANCE FORM / BORANG KEMASKINI SMARTPAY PETRONAS Customer Experience CentreSuite A-1-1, Hampshire Place Office, 157 HampshireNo.1, Jalan Mayang Sari50450 Kuala Lumpur
/ Pusat Pengalaman Pelanggan PETRONAS
TEL 1-300-88-8282 FAX 1-300-22-3333
Authorised SignatoryTandatangan Pengesahan
Name:Nama:
Date:Tarikh:
Identity Card No.:No. Kad Pengenalan:
Official Company StampCop Rasmi Syarikat
Approval: Kelulusan:
FORM/SP/M/01/01/201408
Designation:Jawatan:
PUSAT TANGGUNGJAWAB / MAKLUMAT KAD -SambunganB. COST CENTRE/ CARD INFORMATION -Continue
PENGESAHAN DAN SOKONGANC. DECLARATION AND ENDORSEMENTUNTUK KEGUNAAN PETRONASD. FOR PETRONAS USE
Request Type (Please tick (√) one)
Jenis Permohonan (Sila tanda (√) satu)
Card Type (Please tick (√) one)
Jenis Kad (Sila tanda (√) satu)
Product Category (Can tick (√) more than one)
Kategori Produk (Boleh tanda (√) lebih daripada satu)
I/We confirm that all information contained herein are true and complete and authorise PETRONAS Dagangan Berhad to verify from whatever sources PETRONAS Dagangan Berhad may consider appropriate. I/We hereby acknowlegde that the Card may only be used subject to terms and conditions of the PETRONAS SmartPay Fleetcard Cardholder agreement.
“By submitting this application and/or continuing to transact with Petronas Dagangan Berhad (“PDB”), you are deemed to have agreed and consented to the collection, processing, use, disclosure and retention by PDB of your personal data in the manner as set out in the Personal Data Notice given pursuant to Section 7 of the Personal Data Protection Act 2010, which can be viewed at www.mymesra.com.my/pdpa”