HSBC’s Recurring Bill Payment Application Form

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Effective 9 May 20161 Issued by HSBC Bank (Singapore) Limited (Company Registration No. 201420624K).

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†Please refer to the top right of the StarHub bill(s) for the payment code.

Note: The approval of this authorisation will supersede existing payment instructions in StarHub system for the payment code(s) indicated in the respective Billing Account No(s).

Yes, I would like to pay my bills with my HSBC credit card.

Full name (as in NRIC/ Passport)

By signing here, I certify that I have read and agreed to the terms and conditions mentioned below and hereby authorise the respective billing organisation(s) to charge the bills/charges/fees to my HSBC credit card.

(H) (O)Contact No.

Credit card no.

Tanjong Pagar Town Council

Reference number:

Reference number:

Jalan Besar Town Council

Ang Mo Kio Town Council

Reference number:

I hereby authorise StarHub to charge all charges and fees in the monthly StarHub bill(s) for the above stated payment code(s) to my HSBC credit card.

StarHub Payment Code(s)†:

Date

Signature of Applicant

Date

Signature of Applicant

NRIC/ Passport no.

Personal Particulars

StarHub

Y YM M

Credit card expiry date

Town Council(s)

Date

Signature of Applicant I hereby authorise the above selected Town Council(s) to charge my monthly Service and Conservancy Charge (S&CC)/License Fees (TOL) to my HSBC credit card.

Note: The approval of this authorisation will supersede existing payment instructions with the selected Town Council(s) for the respective Reference No(s). indicated above.

I hereby authorise Community Chest to charge the above stated donation to my HSBC credit card.I understand and provide consent that information may be disclosed to Community Chest to facilitatethe relevant tax deduction for my donation.

I pledge to donate (please tick accordingly)

Amount: S$10 S$30 Other: S$ Frequency: Monthly One-time

Date

Signature of Applicant

Community Chest

Every dollar donated to Community Chest will go towards helping children with special needs and youths-at-risk, people with disabilities, frail and lonely elderly and families facing difficulties.

General Terms & Conditions of HSBC’s Recurring Bill Payment Service (the “Service”)By applying for and accepting this Service, you agree to be bound by these terms and conditions. All HSBC debit cards and HSBC credit cards that are not issued in Singapore, HSBC Corporate and US dollar credit cards are ineligible for this Service. Only duly completed applications will be processed. • Your eligibility for this Service is also subject to approval from the respective organisations. • Upon receipt of your application together with all supporting documents, HSBC requires at least six weeks to process your application. • During the processing period, you shall continue to make payment to the relevant organisations until such time as the first recurring payment is charged to your HSBC credit card and reflected on your monthly HSBC credit card statement. • HSBC will not notify customers separately on their application status. Customers are to contact the relevant organisations directly to enquire on the status of their application. • You represent and warrant that the information you have provided is true and correct and authorise HSBC to disclose such account details to the relevant organisations as may be necessary to facilitate your application for this Service. • HSBC reserves the right to reject or decline any application that is incomplete at its discretion without giving any reasons. • The posting of monthly recurring bill payments by the relevant organisations to your HSBC credit card account is beyond HSBC’s control and HSBC is not liable in any manner whatsoever, for the late, delayed or non-posting by the organisations. • If any recurring bill payment charged to your HSBC credit card is unsuccessful for any reason whatsoever, you will be responsible for arranging payment to that organisation by other means. • All accounts with the relevant organisations must be in the same name as shown on your HSBC credit card statement. • Your HSBC credit card account must be in good standing and conducted in a proper and satisfactory manner determined by HSBC at its discretion for the application of this Service. • For the purpose of this Service, eligible applications made by both the main and supplementary credit cardholders will be consolidated under the main credit card account. • In the event your HSBC credit card is replaced with another eligible HSBC credit card, you shall immediately notify the relevant billing organisations and provide them with your new HSBC credit card number, if you wish to continue this Service. • In the event your HSBC credit card is cancelled or you wish to cancel this Service, you shall be solely responsible to notify the relevant organisations and make alternative payment arrangement to the relevant organisations. • HSBC is not liable for any loss, expenses, delays, mistakes, neglect or omission in the transmission of recurring bill payment under this Service. • HSBC reserves the right at its discretion to vary, delete or add to these terms and conditions from time to time without prior notice. • All information is accurate at the time of printing or posting online.

Data Protection Policy The personal data you are submitting is being collected for the purposes stated in HSBC’s Data Protection Policy, a copy of which may be found at http://www.hsbc.com.sg/1/2/miscellaneous/privacy-and-security.

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How to use the Business Reply Envelope (BRE)

ssenisub otni stnemucod tresnI.senil dettod gnola dloFreply folder, folding inwards.

Seal along edges of folder withclear tape (do not staple).Drop sealed folder into post box.

Seal here with clear tape

Seal here with clear tape

Have you signed the form?

Please note:

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POSTAGEWILL BE PAID

BY ADDRESSEEFOR POSTING IN

SINGAPORE

HSBC Bank (Singapore) Limited

BUSINESS REPLY SERVICEPERMIT NO. 01259

Service Delivery - Cards ServicesRecurring Bill Payment ServiceRobinson Road P.O.Box 896

Singapore 901746

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