TEL. NO.

1
PERSONAL DATA
PUBLIC BANK CREDIT CARD ONLINE APPLICATION FORM
2
PROFESSION
4
EMERGENCY CONTACT
3
CREDIT DATA
5
PERSONAL IDENTIFICATION NUMBER (PIN)
NEW NRIC NO. NAME TO APPEAR ON CARD
FULL NAME AS IN NRIC / PASSPORT
DATE OF BIRTH (DD-MM-YY)
HOME ADDRESS
POSTCODE STATE NATIONALITY
IF YES, PLEASE PROVIDE DIRECTOR / STAFFS NAME
ARE YOU RELATED TO ANY DIRECTOR / STAFF OF PUBLIC BANK BERHAD OR ITS SUBSIDIARIES? YES NO
RELATIONSHIP TEL. NO.
OFFICE ADDRESS
ANNUAL SALARY (RM) SOURCES OF OTHER INCOME (IF ANY) AND AMOUNT (TO ENCLOSE SUPPORTING DOCUMENTS)
YES, I WISH TO RECEIVE THE (PIN) WHICH WILL PROVIDE ACCESS TO A WORLDWIDE NETWORK OF VISA / MASTERCARD AUTOMATED TELLER MACHINES (ATM)
SEX
MALE FEMALE
OLD NRIC / PASSPORT NO.
HOME TEL. NO. HANDPHONE TEL. NO.*
EMAIL ADDRESS MOTHERS MAIDEN NAME IN FULL ( A MUST FOR SECURITY VERIFICATION)
Please enclose photostat copy of NRIC (both sides)
NAME OF EMPLOYER / COMPANY NATURE OF BUSINESS POSITION
MONTHLY EXPENSES (RM)
OFFICE TELEPHONE & EXTENSION
I HEREBY APPLY FOR : TICK where appropriate
INCOME REQUIREMENT
PUBLIC BANK VISA
PUBLIC BANK MASTERCARD
Access: www.pbebank.com/cards
PAGE 1 OF 2
NAME OF PREVIOUS EMPLOYER / COMPANY (IF LESS THAN 2 YEARS IN PRESENT EMPLOYMENT)
TEL. NO.
POSTCODE STATE
POSITION
NAME EMAIL ADDRESS
YEARS OF SERVICE
RM80,000 PER ANNUM
PB VISA PLATINUM B VISA PLA LL TINU A
PB PLATINUM MASTERCARD INUM MASTE
PB VISA GOLD
RM25,000 PER ANNUM
PB VISA GOLD
PB GOLD MASTERCARD GOLD MASTERC
PB ESSO-MOBIL VISA GOLD
RM24,000 PER ANNUM
PB-AIA VISA GOLD
RM36,000 PER ANNUM
7
MY CARD DELIVERY AND BILLING OPTIONS INSTRUCTIONS
6
SMS TRANSACTION ALERT (*Handphone tel. no. is required)
8
DECLARATION
IMPORTANT
Kindly return the completed application form to:
FAX : 03-2166 8799
EMAIL : pbcs_online@publicbank.com.my
PLEASE SELECT YOUR PREFERRED THRESHOLD AMOUNT :
RM500 RM1,000
PLEASE ENCLOSE THE FOLLOWING DOCUMENTS :
Completed and signed form
Photocopied NRIC (front and back)
Supporting documents as follows :

SOURCE OF INCOME
Employed
Self - employed
Latest 1 month payslip or
Latest EA Statement or
Latest EPF Statement or
Latest 1 year Tax Returns / Tax Receipts
MINIMUM SUPPORTING DOCUMENTS

RM2,000 RM3,000 RM5,000

OPT OUT (DO NOT SEND ANY SMS TRANSACTION ALERT TO ME. I UNDERSTAND THE RISKS ASSOCIATED WITH THIS OPTION)
SOURCE CODE
Access: www.pbebank.com/cards
PAGE 2 OF2
PLEASE SEND MY CARD TO : HOME ADDRESS OFFICE ADDRESS
PUBLIC BANK BRANCH
OFFICE ADDRESS HOME ADDRESS PLEASE SEND MY STATEMENT TO :
(DELIVERY CANNOT BE MADE TO P.O.BOX ADDRESS / OVERSEAS ADDRESS)
PLEASE SPECIFY
(BRANCH NAME)
by the Terms and Conditions of the Card. I/We agree to pay the prevailing annual fees upon approval. I/We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as
those of the Supplementary Cardmember(s). The Supplementary Cardmember(s) however, shall only be responsible for his/her own liabilities and obligations. The Bank shall reserve the absolute right to approve or reject my/our application as the
other debt collection agent, companies which are related to the Bank by virtue of Section 6 of the Companies Act 1965 at any time and without notice or liability, any information relating to my/our affairs, banking accounts or conduct thereof (including
my/our credit standing) to such extent and for such purposes as the Bank may in its absolute discretion deems necessary or expedient. I acknowledge that if my card application is approved, the yearly Annual Fee payable on the Card shall be waived
as per terms stipulated provided my Card Account is maintained to the satisfaction of the Bank, my Card Account shall remain active for the duration of this period and there is no change in my credit standing as made known to the Bank. The Bank
FINANCIAL SERVICES ACT 2013 (FSA) AND BNM GUIDELINES ON PRODUCT TRANSPARENCY AND DISCLOSURE
PERSONAL INFORMATION
My/Our preference is indicated below:
I/We understand that I/we am/are entitled to obtain access to and to request correction of any personal information held by the Bank and that I/we can inform the Bank to cease using my/our personal information for the purposes above and that
such request can be made in writing to the Bank at my/our account holding branch or by sending it to Customer Service Department, 13th Floor, Menara Public Bank, 146 Jalan Ampang, 50450 Kuala Lumpur.
branches.
POSITION HELD DATE FROM TO
Please sign here with dark black ink only.
Signature must not exceed box boundaries.
PRINCIPAL CARD APPLICANT
DATE :
X
DECLARATION BY NON-MALAYSIAN APPLICANT (TICK WHERE APPROPRIATE)
NO, I / MY IMMEDIATE FAMILY MEMBERS DO NOT HOLD
CURRENTLY HOLD HAVE HELD
HAVE NEVER HELD SENIOR PUBLIC OFFICE
YES, I / MY IMMEDIATE FAMILY MEMBERS
BNM GUIDELINES ON CREDIT CARDS
For new applicants who earn RM36,000 or less per annum:
SERVICE TAX
I/We declare that the Bank is entitled to charge my/our credit card account with the service tax, as may be prescribed by the Royal Malaysian Customs Department
from time to time, which currently is RM50 for every principal card and RM25 for every supplementary card issued, renewed or upgraded and I/we hereby authorise
the Bank to make the relevant tax payment of the same to the Royal Malaysian Customs Department.
I presently hold credit cards from two (2) or more credit card issuers. I intend to apply for a new Public Bank Credit Card now. I shall cancel my existing credit
card(s) with the other credit card issuer(s) upon receipt of the Public Bank Credit Card. Should I fail/refuse to cancel the other credit card(s), I shall inform the
Bank and the Bank shall be entitled to cancel/revoke my use of the Public Bank Credit Card.
I presently do not hold any or am holding only one (1) credit card in my name issued by another credit card issuer.
GOCBWB0513