SmartMedi 2.0 3 EASY PAYMENT PLAN (EPP) / FULL PAYMENT FORM tn consideration of MM International So. Bhd. agreeing to accept my application fr Membership under the SmartMed /SmartMed Deductible Membership Program. 1 RICNo, hereby authors PATHLAS WEALTH MANAGEMENT (SDN BHD [collecton agent fr MXM Ikernaonal Sn Bh charge the Membership Fee payable In acordonce with ay prefered payment plan as indicated below. Step 1 smartMec Sees Wisco M350 Mi so0-vie ml 3so-vip | MM s00-0 350-0 500- vino 350- viPD Step 2: Age Of eed Ee SmartMedi Xtra POD ect} azar s2xa s2xam aM Step 3 Yer) ord Holder's Name INRICNo. (new) el ve) ro} (Hse ‘CVV / CID Number (Lost 3 digit on the signature panel) —__________ (for EPP Payment ony) (| @ i 1s NED orchoider’ Senate ome "THRO PARTY CREDIT CARD AUTHORIZATION u atc here authori the wage of my cei card fr purpove of application formersbehip under the SmariMed /SertMedi Deductible Membership Progam: Cardholder’ Signature WU Cheque No suing Bonk Cheque shouldbe made payable to Pathla Heath Management (M) Sdn Bhd (Co, No, 295313 M1 Step 4 ESEMINAR SDP A TOO MOTT "hereby authorize MAM INTERNATIONAL SDN BHO or ATHLAB HEALTH MANAGEMENT (M) SDN BHD (collection agent for MXM International Sdn Bh) to aut charge my during renewal may wary ve ochange of age band or revo to the Membership Fee and/or rewsian to the Insurance Pemvsm impored bythe Insurance Undrariter() “his authorization aalremainvalsand eet unl cancel by malin writing to MM INTERNATIONAL SON BHD 3 eae Sty 60) Daye par othe expr of my prevailing ‘Membership Netwhstanng the sboeinsucton, agree tit my Membership maybe terminated fhe Membership Fe sR pa when epee to norm MBM luring of any changes pertaining tot Tc ak] Ron os osMEMBERSHIP PAYMENT MODE - SmartMedi aes! EASY PAYMENT PLAN (EPP) / FULL PAYMENT 1 aie spi tor saree! PRINCIPAL rogram smartMedi " 2 cee x SEs Pear al MOOT Pc Coren Peer 13-25 [mvaesas | wasoas | nmzouzaa [mnaaasao |[ nmzoom [ awassco | mwa | awi.cori0 nas wzonas [ amazes | mwas | maaan || wraisas | ewasisi [mwaaeiao | wnnere20 fis. | reo? sone | awzeiai | amaones | mwaicno | awazeoq || awaiaze | mwasras [amasance | auzcsomn | Man | Rcoey ices | aorneass | mwareas [mwaonaia | amaoesar|[ amraoaao | mwaiaao | nmasoo.e | awraconae 76-e0veneneonyt [ aweaisy | ewssias [aw77saa6 [amezn20 || aw7e2a0 | mwosua [amass | an7s020 forsmartved SPOUSE / JUNIOR Program ee pox Pong ed wi roe 20¢ays-18 union) | aweas7aa | nm e251 | eMi.26620 | am e026 |] rm s3093 | aM 97.02 | awa.ezea0 | RM x04226 19.25 zer7e | mwaizee | awa.eisa2 | awaziaz0 |] awiaaos | awaavas | amaoirae | awia0sa0 55 awaiore | awasese | aw2siece | awi.coea6 |] awas2a0 | awaoeso | aMaseice | Auieea | Addttona! | Adtional 36-60 awaeiza | mmaeese | awssace | awzar-00 || amaaso7 | awaiser | amazes | AM244700 | pecaontn | per onth 71-75 enewalonn) [| aMsiaa0 | amasase | Rwsq0396 | amso2920 || amseoor | mwsziza | Amsssnse | aM5o2s10 low rir able aplalefor Sarted SENIOR CITIZEN erro Pe pot Doug ea wi eee aes jawiazaz0 | mwaaei0 | awacro.e | awa.ciose |] amavaar | ava? | awazocie | awaavase | Addons! | Adtionsl 6-70 awaazee | rwaest0 | awaseiad | awaetes2 || awsoaco | amaioo2 | aws77240 | AA6032 | perontn | per Month 7-75 enewalonh) | Awae74 | manage | AMSSeI96 | AMaai7a0 || AMsria | RwS0aS7 | AMBAar6 | AMS.7IRI0MEMBERSHIP PAYMENT MODE - Ss AVA NE WAAL we PRINCIPAL rrozran SmartMedi ee pire Deductible Ss posed Dee MT cae pore ora pone 19.25 rem 9005 [ ao a.t05.0 | am wz2a30 | rwa0s22 | powa.aceo | awate76 26.35 rw ona | aoi.25550 | aw o7asal| mwasaas | awiooar | rwaariso | awaaease 555 aiz7as | maioaoy | awiasaco | amaacece || amaazor | awizaas | mwas | awiaaase | Additonal | Addons 35.74 | RM 6087 3660 aaasoa7 | mmaaiaa | awieseae | ama4aoao || amseiz0 | wwaez22 | m226ie | eM,00080 | permionm | pec orn 6165 waaiesa9 | masoaaa | awzorace | amaasaae || amzza06 | awziaae | aw2s7a08 | aM238094 76-80 (renewal oni) [_awai795 | ama9e7s [ Rwas7osa | awaaz7a0 || amaiace | mwso7a2 | razzase | awasose0 ie SPOUSE / JUNIOR Provan SmartMedi pry Peery Peery SE Deh ae pre a pete Ene Eee Ee 0¢ays- 18 4uNIOR) | RM 5807 rw_593.00 | am saiae || ru 7us7 | aa osx | nm 75500 | RM 623.98 5 ma oiae | aM 7238 [aw o7ae0 | aM 7776 || amiooes | am e7ss | rwaaseeo | RM 92076 1655 faaoeae | am o040 | awia7e00 | aM 95764 || amaoiao | amsiza2 | awiaa9.00 | aMi22066 | Additonal | Addon 36-60 raaaaaco | maaia72 | awiasaae | amaaiea0 || amsoasa | awienss | awaaiaae | RM158840 | permtonm | pectonth 7a T5(renewalony) | RM237.74 | A 7066 | AM26N90 | aMzA25«2 || AMatza; | AM2saa9 | Awasa7oe | AMastDR2 Solow ring abl isapoable for Snare Oude SENIOR CITIZEN Provan SmartMedi end r Peres Peery Ey accor | Ra ae OTD yuu parent Conn ee a6 waaias.oc | mataais | awaciace | amaazaae || awsoa7a | awirras | mw2issoa | aw tease | Addons 70 raises | masazsa | aw2aiseoa | am200a7 || amzease | wzeea0 | Am2957.08 | AM2792.74 | permtonm | pec Month 7A-T5(renewalony) | Rz2008 | A200 | AMza2a.8 | AM22I62 || AMaoN7S | RMa7Sa7 | Awaa2508 | AWa,0762 76-80(renewaloniy) | mwrzea2 | winzeia2 | wmajiaesa | awccaao || awaeaza | awacace | wwaasese | awaathe0Seren ate Bank ee RE sedeasa STE ‘neue to bemasepyabie tPathe Heath Managment (Sn Bb ‘choca re ented ome oa ets ash epaton on Maybank Berhad same 20725, FOR INFORMATION ONLY Merchant Minimum Amount fr Sarde /Smarted Dedctbe 2 sane Rabat” ft 6o0.00 ‘004 Frm (photocopy frmcan be vied) 2 Bank Simpanan Nasional x 1900.00 DOA Form photocopy form can be sed) ‘ awe waa 1.20000, ‘DOA Form (photocopy frm canbe used) 6 Mong tone 000.00 ‘0A Form (photocopy frm canbe used) 5 sac fx 00.00 5 Maybank 3,000.00 ° cae na 000.00 DA Foxm orignal form must be submited) a RB fw 1,000.09 2 Standard chartered 100000 2B os 1,000.00 Foe photocopy form can be used) IMemberCade | ProgamCade | Amount | _GSTV@™) | londing | GST/6M) Forla Tecipta Simard iP iP Deductible Smarties ra