28 OCT SmartPay APPLICATION copy - chinesechamber.org.my · PETRONAS Customer Experience Centre...
Transcript of 28 OCT SmartPay APPLICATION copy - chinesechamber.org.my · PETRONAS Customer Experience Centre...
Please complete the form using black ball point pen and BLOCK letters and numbers only.Submission needs to be attached with relevant supporting documents.
Sila lengkapkan borang dengan pena mata bulat dan huruf BESAR dan nombor sahaja.Permohanan haruslah disertakan dengan dokumen sokongan yang relevan.
A. JENIS PERMOHONANTYPE OF APPLICATION
B. JENIS SYARIKATTYPE OF COMPANY
C. COMPANY / INDIVIDUAL PARTICULARS
SMARTPAY APPLICATION FORM / BORANG PERMOHONAN 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
(If subsidy, please specify subsidy number)(Jika subsidi, sila isikan nombor subsidi) (If yes, please specify the account number)(Jika ya, sila isikan nombor akaun)
Berhad Berhad
- Annual Report- Original letter from MDTCC* for Subsidy Application
- Laporan Tahunan- Surat Kelulusan dari KPDNKK* untuk Permohonan Subsidi
- Company Registration Document (Form 9 or 13, 24 & 49)- Memorandum & Articles of Association - Latest Audited Account- Latest 2 month Bank Statements- Original Letter from MDTCC* for Subsidy Application
- Dokumen Pendaftaran Perniagaan (Borang 9 atau 13, 24 & 49)- Memorandum & Perkara-perkara Persatuan Syarikat- Akaun Beraudit terkini- 2 bulan Penyata Bank terkini- Surat Kelulusan Asal dari KPDNKK* untuk Permohonan Subsidi
- Company Registration Document - Copy of Identity Card - Latest 2 years Profit & Loss Statements- Latest 2 month Bank Statements- Original Letter from MDTCC* for Subsidy Application
- Dokumen Pendaftaran Perniagaan - Salinan Kad Pengenalan- 2 tahun Penyata Keuntungan & Kerugian terkini- 2 bulan Penyata Bank terkini- Surat Kelulusan Asal dari KPDNKK* untuk Permohonan Subsidi
- Copy of Identity Card - Latest 2 month Bank Statements- Original Letter from MDTCC* for Subsidy Application
- Salinan Kad Pengenalan- 2 bulan Penyata Bank terkini- Surat Kelulusan Asal dari KPDNKK* untuk Permohonan Subsidi
- Official Request Letter
- Surat Permohonan Rasmi
BERHADBERHAD
SENDIRIAN BERHADSENDIRIAN BERHAD
SOLE PROPRIETOR / PARTNERSHIPPEMILIKAN TUNGGAL / PERKONGSIAN
INDIVIDUALINDIVIDU
GOVERNMENTJABATAN KERAJAAN
SmartpaySmartPay
Diesel SubsidySubsidi Diesel
Petrol SubsidySubsidi Petrol
Subsidy No. No. Subsidi
Existing PETRONAS SmartPay Account HolderPemegang Akaun PETRONAS SmartPay?
Account No. No. AkaunYesYa
NoTidak
Sdn BhdSdn Bhd
Sole ProprietorPemilikan Tunggal
PartnershipPerkongsian
IndividualIndividu
GovernmentJabatan Kerajaan
SUPPORTING DOCUMENTS FOR EACH CATEGORYDOKUMEN SOKONGAN UNTUK SETIAP KATEGORI
MAKLUMAT SYARIKAT / INDIVIDU COMPANY / INDIVIDUAL NAME NAMA SYARIKAT / INDIVIDU
COMPANY / INDIVIDUAL NAME TO APPEAR ON THE CARD (MAX. 25 Characters including space(s))NAMA SYARIKAT / INDIVIDU UNTUK TERTERA PADA KAD (Maks. 25 huruf termasuk jarak)
ADDRESS (P.O Box Address NOT Acceptable) ALAMAT (Alamat Peti Surat Pejabat Pos TIDAK diterima)
E-MAIL ADDRESS ALAMAT E-MEL
POSTCODE POSKOD
TELEPHONE NO. NO. TELEFON FAX NO. NO. FAKS
CITY BANDAR STATE NEGERI
*Ministry of Domestic Trade, Co-operatives And Consumerism / *Kementerian Perdagangan Dalam Negeri, Koperasi Dan Kepenggunaan
MOBILE NO. NO. TELEFON BIMBIT PREFERRED LANGUAGE (Please tick (√ ) one)English
BAHASA PILIHAN (Sila tanda ( √ ) satu)
Bahasa InggerisBahasa Malaysia
WEBSITE LAMAN SESAWANG
CONTACT PERSON NAME NAMA PEGAWAI UNTUK DIHUBUNGI
AUTHORISED SIGNATORY NAME NAMA PENANDATANGAN YANG SAH
COMPANY REG. DATE TARIKH PENDAFTARAN SYARIKAT
IDENTITY CARD NO. NO. KAD PENGENALANCOMPANY REG. NO. NO. PENDAFTARAN SYARIKAT
(yyyy-mm-dd) (tttt-bb-hh)
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.
Authorised SignatoryTandatangan Pengesahan
Name:Nama:
Date:Tarikh:
Identity Card No.:No. Kad Pengenalan:
Official Company StampCop Rasmi Syarikat
Approval: Kelulusan:
FORM/SP/A/02/01/201104
Designation:Jawatan:
F.
COST CENTRE NAME (Optional)NAMA PUSAT TANGGUNGJAWAB (Tidak Wajib)
COST CENTRE LIMIT(Optional)HAD PUSAT TANGGUNGJAWAB (Tidak Wajib)
(RM)
Stan
dalo
nePe
rsen
diria
nDr
iver
Pem
andu
No.
No. Ve
hicl
eKe
nder
aan
Subs
idy
Subs
idi
Flee
t Man
ager
Peng
urus
Ken
dera
an
Card Type (Please tick (√) one)Jenis Kad (Sila tanda (√) satu)
Vehicle Registration No.
No.Pendaftaran Kenderaan
Name To Appear On Card(Max. 25 characters including space (s))
Nama Yang Akan Tertera Pada Kad(Maks. 25 huruf termasuk jarak)
Dies
el
Lubr
ican
tPe
linci
r
Petr
ol R
ON
95
Petr
ol R
ON
97
Keda
i Mes
ra
1
2
3
4
5
Single Transaction
LimitHad SatuTransaksi
Daily Card LimitHad Harian Kad
Purchase Limit (To nearest RM value)Had Pembelian (RM) (Kepada nilai RM terdekat)
Monthly Card LimitHad Bulanan Kad
Count Limit (Optional)Had Kiraan (Tidak Wajib)
Daily Transaction
LimitHad
TransaksiHarian
MonthlyTransaction
LimitHad
TransaksiBulanan
D. PUSAT TANGGUNGJAWAB / MAKLUMAT KADCOST CENTRE / CARD INFORMATION (For multiple cost centre, please fill up separate form) (Sila isikan di dalam borang berasingan jika pusat tanggungjawab lebih dari satu)
E.E. PENGESAHAN DAN SOKONGANDECLARATION AND ENDORSEMENT UNTUK KEGUNAAN PETRONASFOR PETRONAS USE
F.ACCOUNT AKAUN
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:
:
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MONTLY QUOTA (litres)KUOTA BULANAN (liter)
PRE-PAID POST-PAID
START DATE QUOTA (yyyy-mm-dd)TARIKH MULA KUOTA (tttt-bb-hh)
END DATE QUOTA (yyyy-mm-dd)TARIKH TAMAT KUOTA (tttt-bb-hh)
MDTCC REFERENCE NO.NO. RUJUKAN KPDNKK
SALES REPRESENTATIVEWAKIL PENJUALBILLING CYCLETARIKH BIL
COLLECTORPEMUNGUTPRODUCT CODEKOD PRODUK
INDUSTRY CODEKOD INDUSTRI
CUSTOMER CLASSKELAS PELANGGAN
SALES REGIONWILAYAH PENJUALAN
CLAIM TYPEJENIS TUNTUTAN
STATUSSTATUS
APPROVEDLULUS
PENDINGBELUM DILULUSKAN
:
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:
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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
Product Category (Can tick (√) more than one)
Kategori Produk (Boleh tanda (√) lebih daripada satu)
UNTUK KEGUNAAN PETRONAS - SambunganFOR PETRONAS USE - Continue
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