BORANG PERMOHONAN KIRIMAN WANG

PUBLIG BANK ,Effi+ETffi I REMITTANCE APPLICATION FORM

PUBLIC ISLAMIC EANK
Cawangan/hli/Branch TarikhlEFE lDate
(lBG)
Permohonan
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Untuk
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no
Draf Permrntaan As
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Cek Jurubank
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Pindanan
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Giro Antara Banx
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Lain-lain

Application For Fore,gn Demand Dratt Transfer ' (IBG) *-

lnterbank Giro Oihers
- - Banker s Cheque Teteqraohic

PENERIMA / &#,A I BENEFICIARY I Pemastautin/ER/Besldeni ! BukanPemastautin/iFER/Non-Festderf

Bayar Kepada /
Wtsr:qg"{
T ft I t\ailanailw
Y1I I favounno
Nombor Akaun / No. KP/Pasporl/Syarikat /
FDE19 I Accaunt Number 9+tfi"1 tilll ba+fi\ I lClPassportl Company No
59
A amat /
J{,-JII / ArJdress

Bandaraya / Neoara/ Poskod /

$ifr tciy @*, lCountrv fillEffiE / Postcode

BANK PENERIM A I W#ffilI I BENEFICIARY BANK

57
Alamat Bank Penerima / Bandarava /
W*Af?lllblt I Bene'ficiary Bank Address uifi I ciiv
Bullr-but r Pembayaran /
70
fiiltl'l* I Payment Details
PEMOHON / +iFA I APPLICANT fl Pemastauiin/,ER/Fesldent Bukan Pemastautin / 1EER I Norfiesident
Nama Pemohon / No. KP/PasoorVNo. Svarikat /
frE).1t* I Applicant's Name H'hfrt fPF.l LaEE ]C'Passpantconpany No
50
A amat /
itttl //ddress
Warganegara / Jantina / No. TeLefon /
LR I Natlonalitv ,ltf;tl l sex €ifrEfiB / tu/eohone No
Pekerlaan / Nama Maiikan/Pern aoaan / JenLs Perniaoaan/Pekeriaan /
F,l,!! I accupatian Er.l,)14:At.". A/ame-oi Frplo) e/ BLs ness :[*tf 't*tl . Busineis,EmptoymentType

MATAWANG 1fr.fr I CURRENCY AMAUNIXffiIAMOUNT 32A

KAEDAH PEMBAYARAN I IT#.frX, / MODE OF PAYMENT AMAUN & CAJ / trffi 5'&# I AMAUNT &CT{A8GES
Kadarll!#4lRate
tr Cash E
Tuna / I,[,$ / No. Cek / tFE{\ I Cheque Na
Selarul+lElEquvalent

tr A,(/+,ilr,lifn^*fRli,t 6I/+tJ ifi

Saya./Kam memberi kuasa kepada Bank untuk mendebit akaun saya/kami bernombor
F EqiS+l![f +tli
RM
llwe authorise the Bank to debit mylaur account number
,I STAMP DUTY

Llrl WIRE
tr Saya memberi kuasa kepada Bank untuk mendebit VlSp/IiIASTEBCARD Pub ic Bank atau Publ c ls am c Bank
saya bagi permohonan Saham Tawaran Avram Awal (Kad mest dikemukakan).
6/'iE+lFrRlr,tt6/.fiililltRllfiiAEiliF.llfiU+/Ftit+*E[A#U, U+iB+,Itfiffi,ffiF (#H,rr1"=H+), COMMISSION

(Card nusl be presented).

tttitttl TOTAL RM

PENGESAHAN MESIN / iilLW&X I MACHINEVALIDATION

pENGISYTIHASAN
AKTA BANK NEGARA MALAYSIA 2OOg/AKTA PEBKHIDMATAN KEWANGAN 2013/AKTA PEBKHIDMATAN KEI,I,ANGAN ISLAM 2O1O -
oLEHpEMoHoN/2009+S*trw+*fRtiE/2013+#EfEE#r*+/2013+EI#6F(it+-EH^=fi ICENTRALBANKOFMNAYSIAACTzffE.I
FINANCIAL SERY,CES ACT NfiIISAMIC FINANCIAL SEFY,CES ACT 2013 - oEcuRArDI'I BY APPLICANT

fl (A) Barang/6fr/coods E lB) Petalanan ftdaktermasukTambairg Penumpang)/iikfif(4@!f;*E*E)ITravel(ExcludingPassengerFare$ f] (C) Pendidikan/#€/Educailon

fl(D) KhidmatPernagaanLain/E{bB!LEE4/OtherBuslnessSeruices T(E) Pengangkutan/iE{fir-i6/Iransport E(nDlviden/E{,8./avidend | (G) Faedah/fl,-F//nterest

lnl nman wang tseKerla i f ''*'.lWorker'sBemittances

;LrI T()enoalanSemasaLain/-Eft,*Ei$!rl'hlOtherCurntTransfer T(J) PemberiandanHadiah/!lH-5&iLW)lGrantsandGifs
^

f-l 1O) Bon oan wan gKerlas I !fr*&*ffi lBords and Notes ! {e) tnrt,u*.n Pasaran Wang / f fifi ltta{ I Money Market lnstruments
! {Q)set<urit Kerajaan/il!,[ii[#/GavernmentsecLtrities E (B) HartaTafah/ ElfrP lBealEstate I (S)DeposittuarNeger liBll#*-nl,lDeposiisAbroad

! rUr Se air da' oaoa yalg oi atas )) r.rf h1qtfrEtfi a1he, rhan abog

rl
(Kod Tuiuan / ,E
jf ffiE I Purpose Cade)
Akuan Penerimaan / S$ I Acknowledgement

rdyd^dilr ,r E,rvsnd, ud, PU,,rLu,rurra ,Eilg^dP. u,ub,,,49d,,,, dud,dL'

^d,L ldenfiy
sayaikam dan aias r slko saya/kam sepenuhnya dan seterusnya tanpa apa-apa tanggung]awab atau liabi itl kepada iuan, Permohonan saya./kami di Verified
!aLatT,r aoaal rerraKu( Kepaua teillauan Dyatat lJauanaarTatLseo IU seperurilrya.
-lrr-ba.( !'ai a:au aksanakan prndahan tersebui sepefil yang dinyatakan
Nama /
E, n,r. i,.:i=;-=1.;:.iitltE':.iait&.t,ti*litEEii+7Efr*?r.5*1+. iEtsHlsH.itR6qF/itFfr1*r,iiEEH!{tjllitij" llfi / Nane
l,\1,/ecarfirmthailhetf;fctmaiiarre,ei"iscatreciardtheapplicaiianisinorder. Thistransactionisundermy/ouraccountandatmylourriskabsalutely \0. KP /
-^A{,)*h6r ui+t^))!.-trraa^^n-)Aii;n1^.it-Aitli)+^tt^,) iti at 1r.^^t;--t;^nh^.a;n;oo,,A;^-+t^+h^T^t66c^Aa^^Ai+i^--^-thd/^t,^f6^^lthi6E^fht-hi^6 B4liilEfr4 / /c rvo

llwehavereadandfullyunderstood. P/easeissueyourEanker'sCheque/Draftareffectthetransferasspeclfled.

UNTUK KEGUNMN BANK SAHAJA i flH4{?'EE I FAR BANK'S USE O'V[Y

BNM Approval No. FOR MERVA USE