GEN. CIR.

5 1144/2005

Exhibit 4

GLOBAL FILIPINO MONEY CARD APPLICATION FORM

APPLICANTS INFORMATION
APPLICANTS NAME (Last Name, First Name, Middle Name)

DATE OF BIRTH SSS/GSIS ID No. PRESENT ADDRESS PERMANENT ADDRESS

PLACE OF BIRTH CIVIL STATUS

NATIONALITY

TIN

NAME OF SPOUSE (Last Name, First Name, Middle Name)

TELEPHONE NUMBER (Include Area Code) TELEPHONE NUMBER (Include Area Code) OCCUPATION E-MAIL ADDRESS MOBILE NUMBER TELEPHONE/FAX NO. (Include Area Code) POSTAL CODE

NAME OF EMPLOYER/NATURE OF WORK/BUSINESS BUSINESS ADDRESS SOURCE OF FUNDS

I hereby affirm that the information given by me in this application is true and correct. I have read and understood the terms and conditions governing the use of GF Money Card and I agree to be governed by them.

Signature of Applicant

FOR PNB USE ONLY

IDs Presented:

Processed By/Date:

Approved By/Date: