CREDIT CARD PAYMENT REQUEST FORM (MALAYSIA) Company Name: _________________________ FedEx Account No: Name of Contact Person: ___________________ Payment Details: Invoice no Amount Invoice no Amount 1. ________________ ____________ 4. ________________ ____________ 2. ________________ ____________ 5. ________________ ____________ 3. ________________ ____________ 6. ________________ ____________ Total Amount _____________ Currency ___________ (If you have insufficient space to fill up, kindly provide the additional details on another page. Kindly include your account number, invoice number(s), and the payment amount.) Credit Card Details: (Please complete only the first and last 4 digits of your credit card. As required by the Payment Card Industry Data Security Standards (PCIDSS), FedEx is committed to protect our customer’s credit card data. Please do not provide the full credit card number). Credit Card Number: □□□□☒☒☒☒☒☒☒☒□□□□ Cardholder Name: __________________________ Credit Card Expiry Date: □□□□ (mmyy) Cardholder Contact Number: __________________ Cardholder Email Contact:____________________ Card Type: Visa / Master (delete where appropriate) Currency of Card: ___________ I hereby authorize Federal Express Corporation and/or its affiliates to charge all amounts due from me to the credit card as indicated above. I also authorize Federal Express Corporation and/or its affiliates to take all necessary action to obtain payment from the relevant credit card company. This authorization shall continue to be in force until I have expressly revoked it by notice in writing and such notice being received by Federal Express Corporation and/or its affiliates. Such revocation shall not affect any outstanding amount which remains unpaid. I warrant, as of the date below, that the details of the credit card set out above are correct and that the credit card is valid and have not been withdrawn or cancelled. I warrant that I will ensure to notify Federal Express Corporation and/or its affiliates any changes to the credit card information forthwith. I have read, understood and agree to be bound by the Fedex.com Terms of Use at http://www.fedex.com/us/legal/. I also understand and accept how FedEx intends to use my information including credit card information under its Privacy Policy http://www.fedex.com/my/privacystatement/. Signature: _______________________________ Date: __________________________________ (Same signature as on your credit card) (mm / dd / yy) Name: __________________________________ Designation: ______________________________ Please complete this form and fax to 603-7712-4461 or email to [email protected] Our Finance Team will contact you within the next 3 working days, excluding the day received, to complete your credit card transaction Please indicate your preferred time slot to call back. Preferred time slot to call back: AM / PM (delete where appropriate) Please note that the FedEx call back phone line will not be listed Updated as of Jan 2015 .