Coway Self Care | Auto Debit Step 1 of 2 50% Customer Name (As per NRIC)* Customer IC Number* Customer Phone Number* Bank Card Copy (Front Only)** Only Visa or Master Cards is acceptable ** Customer Name on Card* Debit Card - Full Name as per IC, Credit Card - Follow Name on CardNew Card NO (First 6 digit)* New Card NO (Last 4 digit)* Customer New Bank Name* Card Type* Visa Debit Card Master Debit Card Visa Credit Card Master Credit Card Customer Signature*HiddenHP Email Hidden I hereby authorise COWAY (MALAYSIA) SDN BHD to perform auto debit from my card/ account for any outstanding payments. HiddenActive Current/Existing PaymodeTandakan "ACTIVE" dan "CARD" untuk mengisi NOMBOR KAD LAMA BERDASARKAN SISTEM jika proses tukar kad untuk kesilapan nombor kad. (Contoh: ************5527) Jika Regular Mode, pilih Regular. TQ. Active Card Regular Current Paymode* Active (Card Auto Debit) Regular Tandakan "ACTIVE" & isi NOMBOR KAD LAMA BERDASARKAN SISTEM jika proses tukar kad untuk kesilapan nombor kad. (Contoh: ************5527) Jika Regular Mode, pilih Regular. TQ.Customer Current/Existing Bank Name Customer Current/Existing Card No ( First 6 Digit )* Customer Current/Existing Card No ( Last 4 Digit )* New Card DetailsHiddenBank Card Copy (Front Only) (JPG, JPEG Only) Drop files here or Select files Max. file size: 3 MB. Customer Order Number* Monthly Payment (RM)* MOTO FormsGenerate MOTO Form? Yes, Generate MOTO Generate MOTO Form (Auto Deduct Selepas Change Mode) MOTO (One Time) Method Rental HP Name* HP Code* HP Signature*