The Annual Fee
  • RM80 Entrance Fee-WAIVED;
  • Basic: RM35 Annual Fee - 2 Years FREE
  • Supplementary: RM15 Annual Fee - 2 Years FREE
 
Please complete ALL details & enclose a photocopy of your documents :
Requirements
•    Minimum Annual Income: RM24,000
•    Age: Basic: 21 – 55 years old
             Supplementary: 18 years old
Mandatory
Documents required, non-returnable
    Photocopy of NRIC (both sides), including Supplementary applicants; AND

For Salaried Earner
    Latest 3 months salary slip

For Commision Earner
    Latest 6 months salary slip

For Self-Employed
    Business Registration Certificate/Form 9,24 & 49
    Latest 3 months Company bank statement
    Form B
 
Product Disclosure Sheet Fees & Charges

The Diners Club International - Délifrance Cobrand Credit Card Application Form

YES! I wish to apply for the Diners Club - Délifrance Cobrand Credit Card with FREE Diners Club Cardmembership.

Source Code:
DF
02
 17

MY PERSONAL PARTICULARS
Full Name As In IC/Passport:
(please underline Surname)
Date Of Birth:
Sex:
Nationality:
Marital Status:
Old IC/Passport No.:
New IC No.:
Race: Chinese Indian
Malay Others:
 
Status: Bumiputra
Non-Bumiputra
Non-Resident
Local Home Address:
Postcode:
Home Phone No.:
Handphone No.:
Years There :
Own Property Rented
Mortgaged Parents'/Relatives'
Permanent Home Address:
Postcode:
Permanent Home Phone No.:
Email:
Academic Qualifications :
No.Of Dependants :
Mother's Maiden Name:
Primary School :
Please Send My Billing Statement To: My Home My Office
MY WORK
Name Of Employer:
I Am Self Employed Yes    No
Office Address:
Postcode:
Nature Of Business:
Office Phone No.: ext.:
Position Held:
Year Joined: 19   20
Gross Annual Income:
 RM
MY FAMILY
Spouse's Full Name As In IC/Passport : (please underline Surname)
Date Of Birth:

Old
IC/Passport No.:

New
IC/Passport No.:
Hand Phone No.:
Office Phone No.: ext.:
MY EMERGENCY CONTACT
Name Of Closest Relatives/Friend Not Living With Me:
Relationship:
Home Phone No.:
Office Phone No.: ext.:
Hand Phone No.:
MY FINANCIAL PARTICULARS
Loan
(Please tick)		 Interest Rate p.a.
(%)		 Monthly Repayment
 Home Loan RM 
 Car Loan RM 
 Personal Loan RM 
 Other Loan /
Installment Loan		 RM 
 
Please emboss my name on my Card as follows (maximum 25 spaces, to include initials of full name as well)
SUPPLEMENTARY CARD
Please approve a Supplementary Card to the following person (above 18 years of age)
Full Name As In IC/Passport:
(please underline Surname)
Address:
Postcode:
Home Phone No.:
Hand Phone No.:
Date of Birth:
Sex:
Relationship:
Nationality:
Old IC/Passport No.:
New IC No.:
Race: Chinese Indian
Malay Others:
 
Status: Bumiputra
Non-Bumiputra
Name Of Employer:
Office Phone No.: ext.:
Office Address:
Postcode:
Hand Phone No.:
Position Held:
Gross Annual Income: RM
Please emboss my name on my Card as follows (maximum 25 spaces, to include initials of full name as well)
DECLARATION
By signing below, I/we hereby:-
1. Diners Club (Malaysia) Sdn Bhd (3908-K) (“Diners”) to issue the Diners Club-Delifrance International Credit Card(s) (“the Card”) to me/us for my/our use.
2. I/we further request Delifrance Malaysia Sdn Bhd (“Delifrance”) to issue Delifrance membership card(s) to me/us and I/we agree to be bound by the terms and conditions of Delifrance.
3. I/we request that my/our Delifrance Annual Membership Fee(s) (if any) to be billed under the Diners Club Autobilling Service and agree to be bound by the terms and conditions of the Service.
4. I/we confirm that I/we have been given a copy of the Product Disclosure Sheet and agree to the information, including the fees and charges, contained there.
5. I/we agree to accept and be bound by the Terms & Conditions which accompany the Card, its renewal and replacement and any other subsequent amendments thereto unless I/we return the Card/s cut into halves to Diners.
6. I/we hereby authorize Diners to verify and/or make any checks, confirmation and/or obtain information from any credit reference agencies, financial institutions, authorities on me/us and/or from any other sources as Diners deems fit. I/we hereby acknowledge that Diners at all times shall not be liable to me/us or any party regarding any matters arising from this consent and authorization.
7. I/we further agree and authorise Diners to disclose information to Bank Negara Malaysia regarding my/our credit facilities and my/our account with Diners as may required by law or otherwise and make the relevant credit references with any external parties including but not limited to CCRIS and any credit reference agencies.
8. I/we further agree that the Basic Cardmember shall be responsible for all liabilities and obligations of the Basic Cardmember as well as those of the Supplementary Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own liabilities and obligations.
9. I am/we are not an undischarged bankrupt/s and have no pending legal proceedings and/or execution against me/us.
10. I/we declare that all the above information given is true and correct and agree that Diners reserves the right to decline this application and/or withdraw or cancel the Card/s without assigning any reasons thereto.
11. I/we hereby agree to receive SMS, promotional materials, mailers and telemarketing from Diners and its business partners. I/we hereby give my/our consent for Diners to share my/our information (excluding information relating to my/our affairs or accounts) with Delifrance and/or third parties and/or Diners’ strategic alliance as Diners deems fit for marketing and promotional purposes.
Yes     No
 
Send no money now. Upon approval, Diners Club will bill you for annual fees (if applicable), I/We have read this Membership Form, including it's Terms and Conditions listed above, and agree to its terms.
 
Signature of Basic Card Applicant Signature of Supplementary Card Applicant
Date: Date:
For more information, please call DINERS CLUB's Customer Service Personnel at : 03-2161 1055. Please complete this application form above and mail it together with the necessary documents to : DINERS CLUB (Malaysia) SDN BHD. (3908-k) P.O BOX 11095, 50990 KUALA LUMPUR

For security purposes, please DO NOT send account or confidential information via the Internet or e-mail as it will not be encrypted during transmission. For Malaysia Residents Only.
For Diners Club Use Only
APC1 APC2   R
Basic Card No:
Supplementary Card No:
 

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