APPLICATION FORM FOR

CONSUMER FINANCING

IMPORTANT: Please read our Personal Data Protection Notice ("Notice") and Product Disclosure Sheet (PDS) before completing this form. By giving us your
personal data and signing this form, you are indicating to us that you consent and agree to the terms of our Notice, to the PDS and to terms of this form. Our Notice
and PDS are available on our website at www.muamalat.com.my and from any of our outlets.

The Manager BRANCH :

Bank Muamalat Malaysia Berhad DATE :

I/We wish to apply for the following financing facility and furnish below particulars for your consideration :-

TYPE OF APPLICATION: Single Application Joint Application

TYPE OF FACILITY: House Financing House Re-Financing Shophouse/ShopLot Financing Shophouse/ ShopLot Re-Financing
Land Financing Vehicle Financing Non-Vehicle Financing Personal Financing
Educational Financing MCash Bank Guarantee Others:

CAMPAIGN/ PACKAGE: AMOUNT REQUESTED: RM TENURE : years

A. PERSONAL DETAILS (MAIN APPLICANT)

TITLE: ENCIK FULL NAME: MOHD FAUZI BIN MOHD SAFI (as per identification card)

IDENTIFICATION TYPE: New Identity Card Old Identity Card Army IC Police IC Passport

IDENTIFICATION NO: i. New Identity Card 8 30 90 6 - 0 1 - 6 0 4 5

ii. Old Identity Card/ Army IC/ Police IC/
Passport
CURRENT ADDRESS: DATE OF BIRTH: 0 6 - 0 9 - 1 9 8 3 AGE: 3 8 years
ADDRESS E25/13 RESIDENSI PANDANMAS 2 CITIZENSHIP: Citizen Non-Citizen Permanent Resident
LORONG DELAPAN, KG.PANDAN BUMIPUTRA STATUS: Yes No
POSTCODE 5 5 1 00 TOWN KUALA LUMPUR GENDER: Male Female
STATE W.P KUALA LUMPUR COUNTRY MALAYSIA RACE : Malay Chinese Indian Others:………

RESIDENTIAL STATUS: Owned Employer's Quarters Relatives Rented RELIGION : Islam Christian Hindu

STAY DURATION: 3 years Buddha Others:………..

TEL NO. (H) - FAX NO. - HIGHEST EDUCATION : Primary Secondary Tertiary
TEL NO. (H/P) 0 1 2 - 2 4 2 8 6 6 3 EMAIL [email protected] Master Doctorate Professional
MARITAL STATUS: Single Married Widowed Divorced
HOMETOWN ADDRESS: NO. OF DEPENDENTS: < 12 years old 12 - 18 years old
ADDRESS NO 27JALAN BIRU 2 > 18 years old
TAMAN PELANGI MOTHER'S MAIDEN NAME: ZALEHA BTE ARIFIN
POSTCODE 8 5 0 0 0 TOWN SEGAMAT
STATE JOHOR COUNTRY MALAYSIA RELATED TO BMMB STAFF: Yes No
If yes, please specify: Staff Name/ ID No.:
TEL NO. - PREFERRED MAILING ADDRESS: Relationship:
FAX NO. - Current Hometown Dept./ Branch:

B. EMPLOYMENT DETAILS
CURRENT EMPLOYMENT

EMPLOYER'S NAME: SK. BRICKFIELDS 1

NATURE OF BUSINESS: OCCUPATION: TEACHER
TYPE OF EMPLOYMENT COMPANY: POSITION:
Government Agency Conglomerate/MNC Listed Company at Bursa Malaysia Clerical/ Gen. Admin Managerial Professional Self-employed
Financial Institution Public Ltd. (Bhd) Private Ltd. (Sdn Bhd) Officer/Executive Director Uniform body Others
Partnership Sole-Proprietorship Others: ………………………………
DATE JOINED: 0 2 - 0 1- 2 0 0 5
EMPLOYER'S ADDRESS: YEARS OF SERVICE: 60 years
ADDRESS SK. BRICKFIELDS 1
JALAN SULTAN ABDUL SAMAD EMPLOYMENT STATUS: Permanent Contract Self-employed

POSTCODE 5 0 4 7 0 TOWN BRICKFIELDS CONFIRMATION OF Confirmed Under probation N/A

EMPLOYMENT:
STATE W.P KUALA LUMPUR COUNTRY MALAYSIA
60
TEL NO. (O) 0 3 - 2 2 7 4 1 2 4 5 FAX NO. 0 3 - 22 74 1 24 8 RETIREMENT AGE: years
EMAIL : RETIREMENT DATE**: (only if applicable)

PREVIOUS EMPLOYMENT (if any) **If the tenure extends beyond the retirement date, the source of income shall be:
*To be filled if the applicant has less than 1 year of working experience with the present employer. EPF Savings/ FTA/ ASB

EMPLOYER'S NAME: Rental Income Others (Please specify) …............................................

NATURE OF BUSINESS: OCCUPATION:

EMPLOYER'S ADDRESS: POSITION:
ADDRESS Clerical/ Gen. Admin Managerial Professional Self-employed
Officer/Executive Director Uniform body Others
POSTCODE TOWN
STATE COUNTRY YEARS OF SERVICE:
TEL NO. (O) - FAX NO. -

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C. SPOUSE DETAILS
TITLE: PUAN FULL NAME: ISMAWATI BINTI UJANG (as per identification card)

IDENTIFICATION NO: i. New Identity Card 8 4 03 2 6 - 04 - 5 3 16 OCCUPATION: BANKER

ii. Old Identity Card/ Army IC/ Police IC/
Passport EMPLOYER'S NAME: MALAYAN BANKING BERHAD
HOMETOWN ADDRESS: EMPLOYER'S ADDRESS:
ADDRESS 98 RUMAH RAKYAT ADDRESS MENARA MAYBANK
KG. ASTANA RAJA 100 JALAN TUN PERAK
POSTCODE 7 1 3 5 0 TOWN KOTA POSTCODE 5 00 5 0 TOWN KUALA LUMPUR
STATE NEGERI SEMBILAN COUNTRY MALAYSIA STATE W.P KUALA LUMPUR COUNTRY MALAYSIA
TEL NO. (H) - TEL NO. (O) -
TEL NO. (H/P) 0 1 2 - 6 4 3 301 2 MONTHLY INCOME: 8 0 0 0
RETIREMENT AGE: years RETIREMENT DATE:
(only if applicable)

D. REFERENCE (Parents or close relatives who are not staying with the applicant)

1. TITLE: FULL NAME: (as per identification card)

RELATIONSHIP TO APPLICANT: TEL NO. (H) -

HOMETOWN ADDRESS: TEL NO. (O) -

TEL NO. (H/P) -
POSTCODE TOWN
STATE COUNTRY

2. TITLE: FULL NAME: (as per identification card)

RELATIONSHIP TO APPLICANT: TEL NO. (H) -

HOMETOWN ADDRESS: TEL NO. (O) -

TEL NO. (H/P) -
POSTCODE TOWN
STATE COUNTRY

E. MONTHLY INCOME AND EXPENDITURE

MONTHLY INCOME: MONTHLY EXPENDITURE:

BASIC SALARY/ INCOME RM - EPF RM -
FIXED ALLOWANCE: SOCSO RM -
1) RM - OTHER EXPENDITURE/ FINANCIAL COMMITMENT:
2) RM - 1) HOUSE RM -
3) RM - 2) VEHICLE RM -
OTHER INCOME: 3) CREDIT CARD RM -
1) RM - 4) PERSONAL / OD RM -
2) RM - 5) OTHERS:…………………………………………
RM -
3) RM - 6) OTHERS:…………………………………………
RM -

TOTAL GROSS INCOME RM - TOTAL FINANCIAL COMMITMENT RM -

F. EXISTING BANKING RELATIONSHIP WITH OTHER FINANCIAL INSTITUTIONS

FINANCING FACILTY :

TYPE OF FACILITY BANK'S NAME & BRANCH APPROVED LIMIT (RM) O/S BALANCE (RM) MONTHLY INSTALMENT (RM)

G. EXISTING FINANCING RELATIONSHIP WITH OTHER NON-BANK ENTITIES

FINANCING FACILTY :

TYPE OF FACILITY ENTITIES'S NAME & BRANCH APPROVED LIMIT (RM) O/S BALANCE (RM) MONTHLY INSTALMENT (RM)

H. EXISTING BANKING RELATIONSHIP WITH BMMB (FOR BANK'S USE)

FINANCING FACILTY :
TYPE OF FACILITY APPROVED LIMIT (RM) O/S BALANCE (RM) MONTHLY INSTALMENT (RM)

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 FINANCIAL SETTLEMENT & MCRE DEDUCTION:

I/We hereby agree and authorize the Bank to settle the amounts of existing loans and/or financing and other outstanding balances:-

A. Financial Settlement
Estimated Balance Monthly Instalment*
No. Particulars Financial Institution Credited to Account No.
Outstanding* (RM) (RM)

TOTAL SETTLEMENT

(*) Customers are required to provide the current loan / financing statement and/or redemption letter of existing facilities or photocopy of credit cards as proof
for settlement references.

I/We hereby agree and authorize the Bank to deduct the following Moving Costs & Related Expenses (MCRE) and/or Security Deposit (SD) directly from the
facility amount:-

B. MCRE Deduction (For Home Financing only)

No. Item Total (RM)
1 MRTT
2 Legal Fees
3 Valuation Fee
4 Security Deposit
5
6
TOTAL DEDUCTION

Disclaimer :

1 I/We shall not make any claim to the Bank with regards to the above irrevocable instructions unless a written consent is hereby given by the Bank.

2 I/We responsible to inform the exact settlement amount of existing facilities due for settlement. The Bank shall not be responsible if there is any disparity in
the settlement amount. I agree to promptly top up any shortfall should the amount stated in this form is not sufficient to settle the outstanding amount of the
facilities.

3 It is my/our responsibility to inform my/our current financiers once payments have been made by the Bank to ensure that my existing financing accounts
are fully settled and closed. I hereby agree that the Bank shall not be held liable in the event that my existing financing accounts with my current financiers
are not fully settled.

Signed by Customer:
(To be signed by Customer and/or Co-applicant)

Name: Name:

Date: Date:

FOR BANK'S USE- CROSS SELLING

SAVINGS INVESTMENT
RM
Savings Account . RM
Fixed Term Financing . Gold-i Account .
Variable Price Fund (VF) - ASNB .
UT iFast .
WILL WRITING
RM
MyAngkasa Amanah Berhad .
Amanah Raya Berhad .
As Salihin Trustee Berhad .

TAKAFUL-PERSONAL ACCIDENT Other products and services

RM RM
M-Tiara Prestige Protection . M-Jannah Individual .
(Plan 1 - Plan 7) M-Jannah Family .
M-Jannah Warga Emas .

Staff Name: RM
Badal Haji dan Umrah (BHU)
BHU 1 .
Staff No: BHU 2 .

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 APPLICANT'S DECLARATION
1. I/We hereby declare that the information given in this financing form and other documents are true and I/We do not conceal any information that may affect
my/our application.
2. I/We hereby declare that I have disclosed in full all of my/our outstanding financing including with non-financial entities. My/Our failure to disclose any
outstanding financings I/we have or any inaccuracy or misrepresentation shall not attribute to the bank’s failure to adhere to BNM guidelines. The bank
reserves the right to review, cancel or terminate the facilities due to non-disclosure, inaccuracy or misrepresentation.

3. I/We have read the Bank’s Personal Data Protection Notice (“Notice”) and Product Disclosure Sheet (PDS) before completing this form. By furnishing
my/our personal data and signing this form, I/we hereby give my/our consent and agree to the terms of the Notice, to the PDS and to the terms of this form.

4. I/We have not committed any act of bankruptcy as defined under Section 3 of the Bankruptcy Act 1967.
5. I/We hereby authorize the Bank to contact my/our employer or any party to obtain any information required by the Bank.
6. I/We hereby authorise my/our employer to disclose my employment information to BMMB to assist in this financing application.

7. I/We hereby give my/our consent for BMMB to proceed with the credit checking with any credit reference agencies. Pursuant to that, I/We hereby authorize
the Bank to give, furnish, divulge or otherwise disclose, to the said credit reference agencies of any information, statements or facts with respect to the matters
relating to my/our facility(ies) or account(s) with the Bank.

8. The Bank has the right to decline or reject my/our application should the Bank in its absolute discretion decides that my/our credit appraisal quality does not
meet the Bank's requirement. The Bank also has the right to withdraw any of the financing facilities being approved if the information given by me/us is/are
false.

9. I/We hereby give my/our unconditional and unequivocal consent for Bank Muamalat Malaysia Berhad (‘BMMB”) to do the following action for the purposes
of account opening or any other relationship establishment with BMMB:-
a) Conduct searches on any of my/our credit information, including credit information where I am/we are a joint applicant or to which I am/we are or
have been linked and resides in the records of the Credit Reference Agency or any information in the record for the Central Bureau, Bank Negara
Malaysia (“BNM”) (including the Central Credit Reference Information System (CCRIS), the Dishonoured Cheques Information System (DCHEQS) or
any other database or system established by BNM ; and

b) Conduct credit check (s) on me/us for credit review, credit evaluation, debt recovery purposes and legal documentation relating to the facilities of
contract (s) granted or to be granted by the financiers or other persons on me/us; and
c) Use the monitoring applications and obtain new information and updates on me/us and/or my/our company/business from other available sources ;
and
d) Provide the relevant Credit Reference Agency with my/our personal details with respect to the above matters.

10. I/We hereby agree and confirm that I/We shall not hold BMMB liable or responsible for:
a) Any statement, misstatement, inaccuracy or omission of any type of manner contained in the credit information, records and/or credit reports provided
b) BMMB’s reliance on such credit information, records and/or credit reports provided by the relevant Credit Reference Agency and Central Bureau, BNM
to arrive at a decision in relation to my/our application for credit and credit-related or other products or services of BMMB; and

c) Any disclosure of my/our Credit Information by the relevant Credit Reference Agency to any of the other subscribers of Credit Reference Agency and
Central Bureau, BNM in connection with the credit reporting services provided.

11. This Consent shall be without prejudice to any other clause in BMMB’s Term and Conditions for the operation of the accounts or other products or services of
BMMB which I/we have applied for herein and shall remain valid and binding against me/us so long as I/we remain a customer of BMMB.

12. Option and Appointment of Sales Representative (Wakalah) - [Tawarruq-based Financing only]

Leave the commodity at the Bank's possession and hereby irrevocably appoint Bank Muamalat to be my/our representative/agent to sell the commodity
to any third party purchaser for the purpose of availing the financing amount.

Take Delivery of the Commodity.

13. Agreement on Financing of Sales Proceeds (Qard) - [MCash only]

I/We hereby agree to place the commodity sale proceeds as profit free financing under the principal of Qard to Bank Muamalat and to utilize the placement
sum for the MCash usage purpose.
Agree
Disagree

14. We may use your Personal Data:

1. to conduct market research and surveys with the aim of improving our products and services;
2. for marketing purposes, promotional events, competitions and lucky draws related to this application.
We process your Personal Data for these purposes because it is in the interest of our business to do so with the intention of improving our products and
services and generating business. We will not send you marketing material if you have specifically asked us not to do so.
You have the right to opt out of receiving marketing material at any time. To do so please contact your branch or customer service. If you ask us not to send
you marketing material or other promotional or research material, we may need to retain a record that you have asked us not to do so to ensure that you do
not receive anything further.

Signed by Customer:

Name: Name: Authorised Company Chop & Signature

Date: Date: Date:

FOR BANK'S USE ONLY

Interviewed by: Remark (if any):

Name & Staff

Designation

Date:

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