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    1 Individual Customer Front

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    KAng

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    © All Rights Reserved
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    1 Individual Customer Front

    Uploaded by

    KAng
    2 views1 page

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    2 views1 page

    1 Individual Customer Front

    Uploaded by

    KAng

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    REVISED NOVEMBER 2015

    CLIENT INFORMATION AND SPECIMEN SIGNATURE CARD (CISSC)


    (DEPOSIT ACCOUNT) INDIVIDUAL
    Customer No.
    CUSTOMER
    Type Code: Personal Sub-type code: 10 - Individual 20 - Sole Proprietorship
    PERSONAL INFORMATION
    First Name (include name suffix: Sr., Jr., III, IV) Middle Name Last Name

    Nickname Nationality

    Present Address ( No./Street ,Subd.,Brgy./Dist./Municipality/City,Province) Country ZIP Code

    Permanent Address ( No./Street,Subd.,Brgy./Dist./Municipality/City,Province) Country ZIP Code

    U.S. Address (if applicable) ZIP Code

    Tax Identification Number (TIN) Residential Phone (Area Code + Tel. No.) Mobile Phone No.

    U.S. Social Service Number (SSN) or Individual Tax Identification Number (ITIN), if applicable U.S. Phone (Area Code + Tel. No.)

    Profession e-Mail Address Length of Stay in the US

    Current Yr Last Yr 2 Yrs Prior

    Valid IDs Presented :


    SSS No. Passport No. ACR No. (For Foreign Nationals)

    Company ID No. GSIS No. Voter's ID No. Others

    Source of Funds: 30 - Business 60 - Other Remittance Gender: M F Civil Status: Separated


    10 - Salary/Honoraria 40 - Pension 99 - Others (pls. specify) Nationality Single Widowed
    20 - Interest/Commission 50 - Overseas Filipino Remittance Married Divorced
    Date of Birth (mmddyyyy) Place of Birth No. of Children Mother's Maiden Name (First Name, Middle Name, Last Name)

    SPOUSE’S INFORMATION
    Name (First Name, Middle Name, Last Name) Profession Date of Birth Tax Identification Number (TIN)

    BENEFICIAL OWNER’S INFORMATION


    Name (First Name, Middle Name, Last Name) Customer No.

    Date of Birth (mmddyyyy) Place of Birth Nature of Work Source of Funds

    Present Address ( No./Street,Subd.,Brgy./Dist./Municipality/City,Province) ZIP Code Country

    FINANCIAL INFORMATION OF DEPOSITOR


    Employer's Name Employment Start Date Job Title

    Employer's Address ( No./Street,Subd.,Brgy./Dist./Municipality/City,Province) ZIP Code

    Occupation Monthly Gross Income


    1 - Employed 3 - Overseas Filipino Worker 1 - Php 30,000.00 & Below 3 - Php 50,000.01 - 100,000 5 - Over Php 500,000

    2 - Self-employed 4 - Retired 5 - Others (pls. specify) 2 - Php 30,000.01 - 50,000 4 - Php 100, 000.01 - 500,000

    SPECIMEN SIGNATURE CARD


    Account Name Account Type

    Initial Deposit Date Opened


    Account Number : Cash
    Date Updated
    Check

    PLEASE ATTACH
    ID PICTURE

    Left Thumbmark Right Thumbmark

    (This portion shall be accomplished if client is unable to write.)


    3

    LAND BANK OF THE PHILIPPINES (CLIENT INFORMATION AND SPECIMEN SIGNATURE CARD (DEPOSIT)) 11” X 7” 12-02-2015 / KATHRYN /JO 2015 / LANDBANK CLIENT INFORMATION AND SPECIMEN
    CSO NO. 12406

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