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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”
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