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Perjanjian ini dibuat pada ____________ (tarikh) di __________________________. BUTIRAN PAJAK GADAI Nama Kedai Pajak Gadai: _______________________________ Alamat: _______________________________ No. Lesen / Pendaftaran: _______________________________ BUTIRAN PENGGADAI Nama Penggadai: _______________________________ No. Kad Pengenalan: _______________________________ Alamat: _______________________________ No. Telefon: _______________________________ BUTIRAN BARANG GADAIAN Jenis Barang: Emas Bentuk (Cincin/Rantai/Gelang/Jongkong): ___________________ Berat: __________ gram Mutu/Ketulenan: __________ (916 / 999) Anggaran Nilai: RM ____________________________ BUTIRAN PINJAMAN Jumlah Pinjaman: RM ____________________________ Tempoh Pajakan: __________ bulan Tarikh Tamat Pajakan: ____________________________ Upah Simpan / Caj: RM ____________________________ TERMA DAN SYARAT