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)

New

Car

dKa

d Ba

ruCa

rd C

ance

llatio

n Pe

mba

tala

n Ka

dCa

rd R

epla

cem

ent

Peng

ganti

an K

adCa

rd L

imit

Upd

ate

Kem

aski

ni H

ad K

adCa

rd A

ctiva

tion

Peng

aktif

an K

adCh

ange

Pro

duct

Penu

kara

n Pr

oduk

Stan

dalo

nePe

rsen

diria

nDr

iver

Pem

andu

Vehi

cle

Kend

eraa

n

Subs

idy

Subs

idi

Flee

t Man

ager

Peng

urus

Ken

dera

an Single Transaction

LimitHad SatuTransaksi

Daily Card LimitHad Harian Kad

Purchase Limit (To nearest RM value)Had Pembelian (RM)

Monthly Card LimitHad Bulanan Kad

Count Limit (Optional)Had Kiraan (Tidak Wajib)

Daily Transaction

LimitHad

TransaksiHarian

MonthlyTransaction

LimitHad

TransaksiBulanan

Petro

l RO

N97

Petr

ol R

ON9

5

Dies

el

Lubr

ican

tPe

linci

r

Keda

i Mes

ra

Name To Appear On Card(For New Card)

orSmartPay Card Number

(For Card Cancellation, Card Replacement, Maintenance, Card Activation & Change Product)

Nama Yang Akan Tertera Pada Kad(Untuk Kad Baru)

atauNombor Kad SmartPay

(Untuk Pembatalan Kad, Penggantian Kad, Kemaskini, Pengaktifan Kad & Penukaran Produk)

Vehicle Registration No.

No.Pendaftaran Kenderaan

PostcodePoskod

SmartPay Account No.No. Akaun SmartPay

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)

New

Car

dKa

d Ba

ruCa

rd C

ance

llatio

n Pe

mba

tala

n Ka

dCa

rd R

epla

cem

ent

Peng

ganti

an K

adCa

rd L

imit

Upd

ate

Kem

aski

ni H

ad K

adCa

rd A

ctiva

tion

Peng

aktif

an K

adCh

ange

Pro

duct

Penu

kara

n Pr

oduk

Stan

dalo

nePe

rsen

diria

nDr

iver

Pem

andu

Vehi

cle

Kend

eraa

n

Subs

idy

Subs

idi

Flee

t Man

ager

Peng

urus

Ken

dera

an Single Transaction

LimitHad SatuTransaksi

Daily Card LimitHad Harian Kad

Purchase Limit (To nearest RM value)Had Pembelian (RM)

Monthly Card LimitHad Bulanan Kad

Count Limit (Optional)Had Kiraan (Tidak Wajib)

Daily Transaction

LimitHad

TransaksiHarian

MonthlyTransaction

LimitHad

TransaksiBulanan

Petro

l RO

N97

Petr

ol R

ON

95

Dies

el

Lubr

ican

tPe

linci

r

Keda

i Mes

ra

Name To Appear On Card(For New Card)

orSmartPay Card Number

(For Card Cancellation, Card Replacement, Maintenance, Card Activation & Change Product)

Nama Yang Akan Tertera Pada Kad(Untuk Kad Baru)

atauNombor Kad SmartPay

(Untuk Pembatalan Kad, Penggantian Kad, Kemaskini, Pengaktifan Kad & Penukaran Produk)

Vehicle Registration No.

No.Pendaftaran Kenderaan

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”