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TERMINATION / REPLACEMENT APPLICATION FORM

Mail to : Card Services Department, PETRONAS Dagangan Berhad, Level 25, Tower 2, PETRONAS Twin Towers, KLCC, 50088 Kuala Lumpur
Tel : 1-300-88-8181
Fax to : 1-300-88-8383
SmartPay Account No

Date

Company Name

Tel

Contact Name

Fax

Type of
Collection :

Request for Termination / Replacement of the following PETRONAS SmartPay Card(s)

No

Card Number

Driver Name

Vehicle
Reg No

Courier
Replace
Yes

No

By Hand

Reason

This request is subject to i) conditions contained in the SmartPay Cardholders Agreement and ii) review by the PETRONAS Card Services Department.

Authorised Signatory

Official Company Stamp

PETRONAS OFFICIAL USE

SmartPay Card Centre Reminder

Process Date:

Ensure the form is complete to

Reviewed:

avoid delay in processing

Name:

Approved:

Designation:

Despatched:

All fields are compulsary