EMV-EHAELED CARD CLAIM LAHDBANX

lardholde/s Name: (Fir$t Name. MktOte Name, GEiT6t6i

/
Addrcssj Phone Number;
=mail
oar6 Numoen
file
Accounl Number (tf appticable): Referenca Number:
I rb.r. *sqrd h. fr& I r tn 6 tuq &@ 4 tu Eq &tui

CLAIM AHDWAIVER
I hereby commit to activate the nerv EMV-enabled card by thanging my PIN at any LANDBANK ATM
termtnal wilhrn
three (3) calendar days upon recsipt. ln case of my latture to do so, I herebi hold the Bank, its omc.r'
snd
employees, free from any liability or damages thal may arise frorn the unauthorizecl tiansactions on my eccount.

REQUEST FOR CARD RELEASE THRU OTHER BRAI{CH

lPlae dstr8aftf
@rti@ @d
'i Md€ dafr€d al tha lsrurrg e.anch)
rh& il

This is to request for the delivery of my new EMV-enabled Card to I-AND8ANK Branch.
Withthisrequest,lherebyrelievetheBank.includingitsofficersandemptoy@ from the
loss, damage or delay of shipping due to force majeure.

Signature ol Cardholdar over prinled Nrne/Date

Uar.ll ?017

Name, Middle Name, Last Name)

Stlnaure oEr Pfiilld t{r.m/Drte

EMV.ET{ABLED CARD CLAIM FORM $P LAI{DBAHK

Cardholde/s Narne: (First Name, Mildle Neme. Lasl Name)
t

Card Number. Account Nurnber (if applicabb): Reference Number:

I
CLNM ANDWAIVER
I hereby commit to activate the new EMV-enabled card by changing my PIN at any LANDBANK ATM terminal wthin
three (3) calendar day$ upon recerpt. ln case of my failure to do so, I hereby hold the Bank, its otficers and
employees, free from any liability or damages that may arise from the unauthorized transactions on my account.

REQUEST FOR CARD RELEASE THRU OTHER BRANCH

(ptoar6 dra-rardth6 tEt8pa I cad ts t.rl8 dsfrfd il t o l*fr\ anncht

This is to request for the delivery of my new EMv-enabled Card to LANOBANK Branch.
With this requsst, I hereby relieve the Bank, including its ofiicers and employses, from any liability arising frorn the
loss, damage or delay of shipping due to force majeure.

Signatt ro ot Ctrdh*ter olrer Prinred NnrerDatc