Apply Auto Debit Customer Name(Required)Customer IC Number(Required)Customer Phone NumberCard DetailsCredit Card/Debit Card Copy(Required) ** Only Visa or Master Cards is Acceptable **Card's Issuer Bank Name(Required)Card Holder Signature(Required)Consent I/We hereby authorize COWAY (MALAYSIA) SDN BHD (“the Company”) to debit/charge the my/our Third-Party’s credit/debit card account for all payments due to the Company. In the event that I/we are using the Third Party’s credit/debit card, I/we undertake and agree that I/we have obtained the above stated Third Party Cardholder’s authorization and prior consent to debit/charge the Third Party credit/debit card account for all payments due to the Company.Agent Name
