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PERMOHONAN UNTUK KIRIMAN WANG/APPLICATION FOR REMITTANCE

D Pindahan Telegraf
Telegraphic Transfer (TT)
D Cek Ju~bank/
Bankers Cheque
~ Giro Antarabank
L.__j Interbank Giro
D Rentas
D Lain'.i.ain/
Other: _ _ __

KAEDAH PEMBAYARAN/ MODE OF PAYMENT

n Tunai/Cash D Debit Akaun/Debit Account No : D Cek Maybank/Maybank Cheque No :
BUTIR-BUTIR PEMOHON / APPLICANT DETAILS AMAUN KIRIMAN & MATAWANG /AMOUITT & REMITTING CURRENCY
Nama / ~me:
Jumlah RM / RM Amount:

Jumlah Matawang Asing / Foreign Currency Amount: /

No ID /ID No: ID Resident D Non-Resident Caj/Charge:
Alamat / Address:
Jumlah /Total :
KADAR TUKARAN / EXCHANGE RATE
Negara / Country : Contract No /Dealing Chit No (If Applicable) :
No. Tel / Tel. No: Kadar /Rate :
Pekerjaan / Occupation : BIJTIR· BIJTIR BANK rENERIMA / BE.NEFICIARY BANK DETAll5
t\O~
/
BUTIR-BUTIR PENERIMA / BENEFICIARY DETAILS / Nama/Name: _LJ.£) Vj7) ~ C-
gJVj ~ No Akaun / Account No/lBAN: CX) · \ 0 C3 - -I" :::, I - "'\ (____) \
No ID /ID No: -0~ r1 '3, - ~N' 1
,I D Resid~t 1 (:::;l_No n-Resident
Alamat / Address:

Alamat/ Address: ('-l 6 , \ D , tJAX0-"7 ..':>IA() J-::, ,4- b lUU f -t1170'-\"'-21 \ Negara/Country:
National Clearing Code(FW /SC)/Swift Code: Intermedi ary Bank:
~ - P\ 3,.J>AY\"70 V ~vve-Q. ~ '1 M ~ ~ 251C,
INeoara/ Coun trv : , ' r,) fl
No. Tel / Tel. No: - v

Sumber Dana Dan ~ ikan Bagi Transaksi Tunai RMSQ,000.00 dan ke at,a~ /For Cash Transaction Amount RMS0,000.00 and above please specify source of fund ft employer ·
S<Jmber Dana/
Source Of Funds:
..___ n 'vv-:; 'vY ,..... o,
__,,:___ _..,,....-- (?°) '
p., lA.,n--.,
·I l /
~1 f_
'...,->
IMajikan/
Employer :
TUJUAN BAYARAN / PURPOSE OF PAYMENT /
Barangan/ D D Pindahan ke akaun sendiri/ D ILain-lain Pindahan/
□
Urus Niaga Modal/
□
Perkhidmatan/
Goods Services Own Fund Transfer Other Transfer Capital Transaction
Derivauf I Urus Niaga Wang Asing/ No Rujukan Kebenaran BNM(Jika Berkaitan)/
Denvatives D Forex Tradin~
D BNM Approval Reference No (II Applicable)

'Bank akan mengetuarkan Borang Akuan Pembayaran (Form P) bagi amaun RM200,001 .00 dan ke atas/ Bank will issue Payment Declaration Form (Form P) for amount RMZOO,OOl .00 and above
PERAKUAN UNTUK TUJUAN PELABURAN DAL.AM DAN LUAR NEGARA DAL.AM MATAWANG ASING I DECLARATION FOR INVESTMENT IN FOREIGN CURRENCY ASSET ONSHORE AND OFFSHORE
D I/We (within its group of entities with parent-subsidiary relationship) do not have any "Domestic Credit Facilities" (as defined herein) from any source.
0 I/We do have Domestic Credit Facilities obtained from ... .................. (resident, i~clu_d ing individuals , corporation & financial institutions) and confirrn that my/our total
investments (Foreign Currency Asset _O nshore and Offshore)_including this applicahon do not exceed RM1 million (for resident in~lividuals) or RM50 Million equivalent in
aggregate for a r esident company (within its group of entities with parent-subsidiary relationship) imposed by BNM Malaysia f,9r"this calendar year.

□ I/We have not utilized any foreign currency credit facilities for any investment (Foreign Currency Asset Onshore and Offshore) .

□ I/We have utilized any foreign currency credit facilities for any investment (For_e ign Currency Asset_Onshore and Offsh~re) ~ut such utilisation does not exceed the
equivalent of RM IO Million (for a resident individual) or RM100 Million (for a resident company w1thm its group of entItIes with parent - subsidiary relationship)

□
I/We have obta ine d Bank Negara Malaysia (BNM) approval for investment (Foreign Currency Asset Onshore and Offshore) and/or utilisation of foreign currency credit
facilities exceeding permitted limit
Saya/Kami mengesahkan bahawa keterangan yang diberikan dalam borang lnl adalah benar dan mematuhi Akta Perkhidmatan Kewangan 201] CAJ PINDAHAN DANA/ FUND TRANSFER CHARGES
dan AJ,,ta Bank Negara Malaysia 2009 . Saya/Kami bertanggungjawab sepenuhnya bagl sebarang maklumat yang tld ak tepat, palsu atau tidak Caj dalam negara dibayar oleh pemohon dan caj di luar
'.empurna didalam borang ini. Saya/Kami juga memberi kuasa kepada Bank untuk memberikan maklumat ml kepada Bank Negara Malaysia D SHA negara dibayar oleh penerima I Local charges to be paid
"""'uru t !.kla Perkhidmatan Kewangan 2013 dan Akta Bank Negara Malaysia 2009. by apphcant and oversea charges to be paid by

I h l d 'k' l · 'k d
~ya / V,;,mj telah membaca dan memahami tentang syarat dan peraturan yang terlulls dt sebelah . Oengan a yg e m1 Ian sega a ns1 0 an
benef1c1ary
tr=,amP;:;;;;;;;;~~:-;::=--:------------1
t:.r,~, •mg Jawab terhadap permohonan ini adalah tanggungan saya/kami. Sedarl itu, sila keluarkan draf /klrimkan sepertl tersebut. D OUR applicant
Pemohon / All local a d
n overseas charges to be paid by

I•:,'··•·<
//r-,. d . . . . th· form is true and correct In full compliance with Financial Services Act 2013 and Central TANDATANGAN PEMOHON /APPLICANT S

.,
..-, .. ~, tcclare that the information given m 15

' ; .:ar,r. ,,r lilalay" a Act 2009.

.
. • . . .
,,! 11~Ia~:ia Act Z009. I/We shall be fully responsible for any inaccurate, untrue or incomplete mformat1on provided m th,s Form . I/We
• . • .1 bl to Bank N""ara Malaysia in compliance with F1nanc1al Services Act 2013 and
' •. , ..r 1'..I· th,- Bank to make this 1nformat1on aval a e ""!)
,--\. /
/ \___ _ /./,,,,
IGNATURE

/ r ·/// / / /
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,,.. rr•ad and u11dersu:,od the Terms ft Conditions set forth herein and thus, I/We hereby instruct you to _issue your draft/effect the ll(/t(/;, --,
.. , , ;,e, ,fl~d and I/We st,all l>ear all risks and responsibility or liability in connection with my/our application for the trans fer herein. t--j::t ~~-:._r_..,;::_..;,:.___.:,____:~~ 1 -~

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