Please complete ALL details & enclose a photocopy of your documents:
Requirements
•    Minimum Annual Income: RM24,000
•    Age: 21 – 55 years old
Mandatory
Documents required, non-returnable
    A photocopy of I/C (both sides)

For Salaried Earner
    Latest 3 months salary slip

For Commision Earner
    Latest 6 months Salary Slip / Commission Statements

For Self-Employed
    Business Registration Certificate/Form 9, 24 & 49
    Income Tax Declaration Form B
 
 
Product Disclosure Sheet Fees & Charges
The Diners Club Personal International Charge Card
YES! I wish to apply for the Diners Club Personal International Charge Card

Source Code:
AB
02
17
Travel Bag:
B
2
My Personal Particulars
Full Name as in IC/Passport:
(please underline Surname)
Date of Birth:
Sex:
Nationality:
Race: Chinese Indian
Malay Others:
 
Status: Bumiputra
Non-Bumiputra
Marital Status:
New IC No.:
Old IC/Passport No.:
Local Home Address:
Postcode:
Home Phone No.:
Handphone No.:
Own Property Rented
Mortgaged Parents'/Relatives'
Permanent Home Address:
Postcode:
Email:
Mother's Maiden Name:
Primary School Name:
Please send my Billing Statement to: My Home My Office
My Family
Spouse's Full Name as in IC/Passport : (please underline Surname)
New
IC/Passport No.:
Hand Phone No.:
Name of Employer:
Office Phone No.: ext.:
Position Held:
My Emergency Contact
Name of Closest Relatives/Friend Not Living with me:
Relationship:
Home Phone No.:
Office Phone No.:
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 
 
I hold the following Credit/Charge Cards:
1. Name of Card:
A/C No.:
2. Name of Card:
A/C No.:
Please emboss my name on my Card as follows (maximum 23 spaces, to include initials of full name as well)
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
(min. RM24,000/p.a)
SUPPLEMENTARY CARD
Please Approve A Supplementary Card To The Following Person (Above 18 Years Of Age)
Please Submit :
Photocopy of I.C. (Both sides) or Passport non-for Malaysian.
Full Name as in IC/Passport:
(please underline Surname)
Date of Birth:
Sex:
Relationship:
Nationality:
Race: Chinese Indian
Malay Others:
 
Status: Bumiputra
Non-Bumiputra
New IC No.:
Old IC/Passport No.:
Local Home Address:
(if different from the Basic Cardmember)
Postcode:
Home Phone No.:
Hand Phone No.:
Name of Employer:
Office Phone No.: ext.:
Office Address:
Postcode:
Position Held:
Gross Annual Income: RM
Please emboss my name on my Card as follows (maximum 23 spaces, to include initials of full name as well)
Declaration
1. By signing below, I/we hereby confirm and declare that I/we have voluntarily provided my/our personal data to Diners Club (Malaysia) Sdn Bhd (“Diners”) and I/we consent to Diners to process my/our personal data to evaluate my application and to issue the Diners Club International Charge Card (“the Card”) to me/us.
2. 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 therein.
3. 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.
4. 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.
5. 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.
6. I/We undertake to pay all sums charged to both the Basic Card and the Supplementary Card and to be jointly and severally liable for each other for the same.
7. I/We am/are not an undischarged bankrupt/s and have no pending legal proceedings and/or execution against me/us.
8. 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.
9. I/We hereby also give my/our consent for Diners to share my/our information (excluding information relating to my/our affairs or account) third parties and/or Diners’ strategic alliance as Diners deems fit for marketing and promotional purposes.

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:
Note :
* Upon first transaction to the Diners Club Card within 60 days from the month of Cardmembership, the activation gift will be credited to your Statement of Account. Diners Club has the right to replace the gift with an item of the same value.
 
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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