Permohonan Autodebit Aman Palestin

BUTIRAN PEMEGANG AKAUN/PARTICULARS OF ACCOUNT HOLDER
Gelaran/Title
Nama Penuh/Full Name*

Nama Awal/First NameNama Akhir/Last Name
No. KP Baru/New NRIC*
Alamat Emel/Email Adress*
No.Telefon/Phone Number*

Phone Number
Alamat/Address*

Alamat Jalan/Street Address

Alamat Sambungan/ Street Address Line 2

Bandar/CityNegeri/State

Poskod /PostcodeNegara/Country
BUTIRAN BAYARAN/PARTICULARS OF PAYMENT

Nama Syarikat Pembayar/Name of Payee Corporation: AMAN PALESTIN BERHAD
Amount Sumbangan/Donation Amount*

RM10RM30RM50RM100RM150Other
Tarikh Penolakan/Deduction Date*

5hb25hb
Kekerapan Bayaran/Frequency of Payment*

Bulanan/Monthly
NOMBOR PEMEGANG AKAUN MAYBANK/HOLDER`S ACCOUNT NUMBER

Bank Pengeluar/Issuing Bank: Maybank Berhad
No. Akaun Bank/Bank Account No.*
Akaun/Account*

Simpanan/SavingSemasa/Current
Jenis/Type*

Individu/IndividualLain-lain/Other
PERAKUAN PEMEGANG AKAUN/DECLARATION BY ACCOUNT HOLDER
Tandatangan Pemegang Akaun/Signature of Account Holder*

Clear
seperti dalam rekod bank/as per bank's record
Tarikh/Date*

DayMonthYear
Jam/HourMinit/Minutes
UNTUK KEGUNAAN BANK/FOR BANK USE
Should be Empty:

BUTIRAN PEMEGANG AKAUN/PARTICULARS OF ACCOUNT HOLDER