CUSTOMER MAINTENANCE AND INSTRUCTION FORM
(Please use black ink in filling out this form.)
Branch of Account:
Date:
Account Name:
Account No.:
Open another Account (to be accomplished by existing Joint Accounts only)
Currency
Type of Product to be opened:
Philippine Peso
ATM Savings
Regular Passbook Savings
Passbook with ATM
Regular Checking
Time Deposit
1, 2, or 3 Year Peso Deposit
Prime Time Deposit
Others
US Dollar
Premium Checking
Remarks
By signing below, I/we confirm that I/we have read and fully understood, and agree to be governed by the Terms and Conditions which are or may be applicable to products, facilities or services rendered/to be
rendered by the Bank, its subsidiaries or affiliates, including but not limited to electronic banking services and other banking products and services. I/We fully understand the corresponding risks entailed in availing of
such banking products, facilities or services. Further, my/our continued use and/or availment of such banking products, facilities, or services shall mean my/our conformity to any and all supplement/s, modification/s or
amendment/s of such Terms and Conditions which may be posted in conspicuous places within the Banks premises or which may be published in any other manner.
Client's Signature
Client's Signature
ATM Card No.
ATM Card Related Requests
Reason
Replacement of ATM Card/s
Defective / Demagnetized Card
Conversion to Cirrus Version
Replacement of PIN
Lost PIN
Forgotten PIN
Request to Block ATM Card/s
Lost Card / Stolen Card
Request to Unblock ATM Card/s
Found Lost / Stolen Card
Lost Card / Stolen Card
Client's Signature
I certify that by signing this form, I witnessed the perforation of my defective / demagnetized card (if applicable). I also agree to pay the replacement fee for my old ATM card. And I am aware that if the ATM Card or
PIN Mailer remains unclaimed after a month from request date, the Bank is authorized to destroy the replacement and I will have to make another request.
Replacement of Lost Passbook / Certificate
Reason:
Client's Signature
Client's Signature
Acknowledgement Receipt
If to be released thru a representative:
Received Serial No.:
This is to authorize the person whose signature appears below to receive the replacement of my lost
passbook / certificate.
_____________________________________
_____________________________________
Client's Signature
Client's Signature
Signature of Client / Authorized Representative
Request for Checkbook Issuance
Printed Name and Signature of
Authorized Representative
(Please use this only if Bank Stub or Written Request from client is not available at the time of checkbook requisition.)
No. of Checkbook(s):
Type of Check
Date Requested
Payment Instruction:
Personal Check
Commercial Check
Debit from my / our account
Cash
Client's Signature
Request for Refund of Miscellaneous Cash Payment
O.R. No. (if applicable)
Date Paid
Purpose of Payment
Amount Paid
Client's Signature
Amount to be Refunded in words:
Amount to be Refunded in figures:
Client's Signature
Php
Request for Retrieval of Check Deposit or Miscellaneous Check Payment
Bank / Branch
Check No.
Amount
1
Client's Signature
2
3
4
Client's Signature
Acknowledgement Receipt of Refund /
Check Retrieved
Received the above:
Refund
Refund
Check/s
Check/s
Signature of Client / Authorized Representative
Form ver. 03.2008
In case of check retrieval by a representative:
This is to authorize the person whose signature appears below to receive the above
_____________________________________
_____________________________________
Client's Signature
Client's Signature
Printed Name and Signature of
Authorized Representative
