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1 Individual Customer Front

This document is a client information and specimen signature card for an individual opening a deposit account with a bank. It collects personal information such as name, address, contact details, identification numbers, source of funds, financial information, employment details, and includes spaces for specimen signatures and fingerprints. The card is used to verify the identity of the client and link them to the account in order to process transactions in accordance with know-your-customer and anti-money laundering regulations.

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Herschell Vergel de Dios
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575 views1 page

1 Individual Customer Front

This document is a client information and specimen signature card for an individual opening a deposit account with a bank. It collects personal information such as name, address, contact details, identification numbers, source of funds, financial information, employment details, and includes spaces for specimen signatures and fingerprints. The card is used to verify the identity of the client and link them to the account in order to process transactions in accordance with know-your-customer and anti-money laundering regulations.

Uploaded by

Herschell Vergel de Dios
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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.)


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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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