SMARTDebt Asia (MY) Client Information & Agreement Form

CLIENT INFORMATION & AGREEMENT FORM

Step 1 of 10

General Information

Consultant's Name (Read Only)

1st Consultation Date*

Consultation Type*

DRP

DIY

SETTLEMENT

BANKRUPTCY

PDPA Compliance Notice

Personal Data Protection Act (PDPA) By clicking the button below, I hearby agree that I have fully read, understand and agree with the Personal Data Protection Act and consent to the collection and use of my personal data for the purposes described.

Your Personal Information

Full Name (As in NRIC)*

Other Name (If Any)

Nationality*

Malaysian

Malaysian
Indonesian
Singaporean
Others

Malaysian NRIC (Blue)*

Blue

NRIC No.*

FIN No.

Date of Birth*

Race (As in NRIC)*

Please select

Please select
Chinese
Malay
Indian
Eurasian
Others

Marital Status*

Please select

Please select
Single
Married
Divorced
Separated

Do you have any children?*

Yes

Phone*

Highest Education Level

Please select

Please select
SPR
SPM
College
Polytechnic
University

Email*

Address (As in NRIC)*

Is your residential address the same as above?*

Yes

Residential address

Employment

Your employment status

Please select

Please select
Employed
Self-Employed
Unemployed

Employment Details

Company name*

Position*

Years of service*

Net Income (After EPF/KWSP deduction)*

Self employment details

Company name*

Designation*

Please select

Please select
Director
Sole Proprietor
PHV Driver
Taxi Driver
Food Delivery
Freelancer
Others

Average Monthly Income*

Unemployment Details

Date of last employment*

Company Name*

Position*

Last drawn pay*

Reason for leaving the company*

Your concerns on debt

What is your concern on your debt(s)? (State 3 points)

Concern no. 1

Concern no. 2

Concern no. 3

List of Creditors

Name of creditor*

Outstanding Amount*

Legality

Spouse Information

Name of Spouse*

Spouse NRIC / Fin No.

Spouse ID Type

Malaysian

Permanent Resident

Foreigner

Your Spouse's employment status

Please select

Please select
Employed
Self-Employed
Unemployed

Spouse's Employment Details

Company name*

Position*

Years of service*

Net Income (After CPF deduction)*

Spouse's Self employment details

Company name*

Designation*

Please select

Please select
Director
Sole Proprietor
PHV Driver
Taxi Driver
Food Delivery
Freelancer
Others

Average Monthly Income*

Spouse's Unemployment Details

Date of last employment*

Company Name*

Position*

Last drawn pay*

Reason for leaving the company*

Child's Information

Child's Name*

Age*

Gender*

Male

Female

Employment*

Student

Employed

Engaging SMARTDebt Asia (MY)

In order to engage us as your consultant in debt management, you are required to make a payment as your commitment to this program.

PROFESSIONAL SERVICE FEE: RM 900

Our service includes:	Affidavits / Documents Preparation.
	Personal guidance through the solution processes till completion of debt repayment.

For your convenience the fees has been broken down into 2 easy options:

One Time Payment:	RM 900
Instalment Plan:	RM 450 (Upon signup)
	RM 450 (The next month after signup)

You can make payment by internet banking transfer using the details below:

Internet banking details:
CIMB Saving Account: 7074722896 - Jumaiyah Binte Abu Bakar

Once you have made payment, please upload a screenshot of the transaction advice by clicking the button below.

Upload transaction advice / receipt*

Upload Transaction Receipt

By signing below, I hereby appoint SMARTDebt Asia (MY) and their professional services, as my Debt Management Consultant.

I also hear by agree that I have fully read, understand and agree with the Personal Data Protection Act and consent to the collection and use of my personal data for the purposes described.

Signature

SMARTDebt Asia (MY) Client Information & Agreement Form

General Information

Your Personal Information

Employment

Employment Details

Self employment details

Unemployment Details

Residence

Residential Information

Your concerns on debt

Creditor

Spouse Information

Spouse's Employment Details

Spouse's Self employment details

Spouse's Unemployment Details

Child's Information

Engaging SMARTDebt Asia (MY)