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