E-Ambiz Balance Inquiry Application Form

Appendix 1

BILLER REGISTRATION FORM

IMPORTANT NOTE: ALL FIELDS ARE MANDATORY OTHERWISE STATED. ONLY FULLY COMPLETED FORMS WILL BE PROCESSED.

KINDLY SELECT THE RELEVANT BOXES BELOW.

GENERAL INFORMATION Application Date Effective Date BUSINESS INFORMATION Company Name Company Registration No Address 1 Address 2 Business Address City State Postcode Country Business Contact No. Business Fax No. Business Home URL Primary Contact Name Contact No. Email Address Secondary Contact Name Contact No.

Email Address

BILLER CODE INFORMATION Biller Code Biller Code Name Product Name Business Category CASA & Payment Types CASA ONLY CARD Payment Limit Checking Min. Max. (MYR) Yes Current/Savings (MYR) Min. Max. (MYR) No Credit Card (MYR) Currency Malaysian Ringgit (MYR)

Ref-1 Length Checking Yes Ref-1 Length Min. Max. No Ref-1 Type Static Dynamic

Ref-1 Check Digit Format : Mod 7, Mod 9, Mod 10, Mod 11, Mod 23, Mod 88 , Mod 99, or Others:

Ref-2 Mandatory Optional Real Time Notification (RTN) Yes1 RTN Method Web Services 1RM 0.05 is applicable per RTN message No Email : Batch FTP

Biller Collection Report (Daily & Monthly) MFTP Email

Email :

JomPAY Biller Registration Form Version Oct 2016 Page 1 of 2 BILLER BANK INFORMATION Master Biller Bank AmBank Berhad Fees & Charges (Exclusive of 6% GST)

Collection Account No. *On Us (MYR) **Off Us (MYR)

*On Us applies for Payment via AmBank/AmBank Islamic CASA CASA/CASA-i and Cards/Cards-i **Off Us applies for Payments via other banks' CASA/Cards Fee MDR *** Fee MDR*** ***Merchant Discount Rate (MDR) is charges for credit card Credit Card MYR + % MYR + % transaction and calculate based on transaction value DECLARATION AND ACKNOWLEDGEMENT BY BILLER

Declaration: i. I/We confirm that all information given above is true. ii. I/We hereby authorize AmBank to verify the information from whatsoever source and whenever means that AmBank considers appropriate. iii. I/We hereby give the consent to AmBank an "irrevocable" authorization for AmBank to disclose or release information pertaining to this application for the purpose of JomPAY registration. iv. I/We hereby undertake to indemnify all or any actions carried out by AmBank pursuant to our consent and authorization given herein and undertake to release AmBank from all its responsibilities in connection with or arising from such disclosure. v. I/We agree to notify AmBank immediately for any changes to the above information. vi. In Signing this Biller Registration Form, I/We hereby acknowledge that I/ We have read and understood and I/We accept and agree to be bound by the terms outlined in the Master Services Terms and Conditions and/or Master Services Agreement (as the case maybe), and the Standard Biller Service Schedule for JomPAY service.

Authorized by:

Name Designation

Date Signature

Name Designation

Date Signature

JomPAY Biller Registration Form Version Oct 2016 Page 2 of 2