Debit/Credit Card Auto Debit Authorisation

I hereby request and authorise Coway (M) Sdn Bhd to debit my Credit/Debit Card account for the following payment as stated below:

Rental Order No.

Rental Processing Fee ("RPF") - RM (one time deduction upon signing this authorisation form)

Monthly Payment
Rental Monthly
From Date To Date Payment of
I clearly understood and agreed that this authorisation is governed by the Terms & Conditions as specified below.

Card Member's name as per Credit/Debit Card

Credit/Debit Card Information

VISA MASTER VISA MASTER

Card Type : Credit Card Credit Card Debit Card Debit Card

Credit/Debit card :

Issuing Bank :

Expiry Date : / (MM/YY)

* I/We hereby confirmed that the above given particulars are correct

Card holder's Signature Card & Signature verified By

Date : Name :
HP/Cody code : Date :

Terms & Conditions For Office Used

For the purpose of these Terms and Conditions, the Company refers to Coway (M) Sdn Bhd (735420-H)(AJL931694)
In consideration of the Company agreeing to accept my authorisation to debit my Credit/Debit Card account for the payment to the Company. I
expressly agreed to the following terms and conditions.
1. I shall accept full responsibility for all transaction arising from the use of my Credit/Debit Card for the settlement of payment due to the
Received Date :
Company.
2. The Company shall not be responsible or liable for any claims, losses, damage, costs and expenses arising from the successful processing
of the debit or the unsuccessful processing of the debit due to exceeding credit limit, malfunction of system, electricity failure and any
other factors beyond control.
Received By :
3. The company is only responsible for making arrangement to debit my credit/debit card account through their Card Centre as authorised
by me. Therefore, for any problems or disputes arising from the processing / debiting, it will be my own responsibility to resolve it with
my Credit/Debit card company.
Order No :
4. I will ensure that the Company is notified in writing of any changes, losses or replacement of my Credit/Debit Card or cancellation of this
authorisation at least one month before next due date. Such changes or cancellation will become effective only after the Company has
duly acknowledged the receipt of such request.
5. The Company may at its absolute discretion at any terminate this Credit/Debit Card debit arrangement without assigning any reasons by
giving me one month notice in writing.
Remarks :
6. The Company reserves the right to change the Terms & Conditions set out herein at any time or from time to time when circumstances
warrant without prior notice to me.
7. I hereby agree to indemnify and keep the Company indemnified against any claims, losses, damage cost and expenses which the
Company may suffer or incur arising from my authorisation to debit my Credit/Debit Card account aforesaid.
8. Payment will be considered as paid only upon successful processing of the debit by the Card Centre.
9. If Coway did not receive full payment from the Customer due to insufficient balance on the Payment Date, Coway shall be entitled at a
later date, appropriate a sufficient amount from the Customer's bank account to settle the amount owing.