C

Cardholders signature

yy

mm

dd

Change of Credit/Charge Card

Amex

Received by

Mobile Number

Stamp

Email Address

Customers Copy

IC / Passport Number

Submission for activation at Celcom branch

Name

Full terms and conditions on www.celcom.com.my

A
m

Mastercard

The monthly rebate is only applicable for customers who are

not enjoying any other Auto Billing related rebate and who
are on a Celcom Exec postpaid plan, any Celcom Broadband
package (except for notebook and netbook bundles) or a
Celcom Biz Account that is paid for by the individual
customer.

Mobile No.
Visa

The monthly rebate on current month payment will only be

given and reflected in the following months bill if current
month payment is successful via Auto Billing.

Type of Credit Card/Charge Card

You hereby agree that the use of Auto Billing is undertaken at

your sole risk. Celcom shall not be liable for, and you agree to
indemnify Celcom against all claims, losses, liabilities
proceedings, demands, costs and expenses (including legal
fees) which may result or which Celcom may sustain in
connection with or arising from the provision of the Auto Billing
service to you.

Expiry date of Credit/Charge Card

In the event you dispute the Auto Billing transaction in your

card statement, then such dispute must be notified to
Celcom within six (6) months from the transaction date. The
charges shall be final and conclusive in the event such
discrepancy is not reported within the stipulated time.

New Auto Billing Enrolment

The Credit/Charge Card must be locally issued.

By consenting on this form, you agree to allow your periodic

Celcom bills to be charged either automatically and/or
manually billed into the nominated Credit or Charge Card
account for settlement as per standing instructions from you
or the Card Issuer. You hereby authorise Celcom to forward
your call transactions, billings and other details to the
Acquiring Bank, the Card Issuer and relevant party for and in
connection with the Auto Billing service.

Terms and Conditions

AUTO BILLING FORM

A. Your details

Address
Alternative Telephone Number

Postcode

B. Your Credit / Charge Card details

(Please tick the correct box)

Diners

Credit Card/Charge Card Number

Cancellation

Card Issuer (Bank)

y

C. Your service details

Celcom Account Numbers to be enrolled for Auto Billing

Account No.

D. Your declaration

I/We confirm that the particulars given above are true and correct and that I/we have read and
agree to be bound by the terms and conditions governing the use of this Auto Billing service as outlined on this
form and on the Celcom website.

As per Credit/Charge Card

Date

Branch/Dealer Stamp

Customers Copy
Celcoms Copy