CARDHOLDER REQUEST FORM

Please check the appropriate box for your request and fill in the required information.

CHANGE IN CARDHOLDER INFO (Please indicate below any change in cardholder info)
New Name (due to change in status) _______________________________________________________________________________________________
New Home / Office Address: ____________________________________________________________________________________
New Home / Office Telephone: __________________ New Mobile No. __________________ New Email Address: ________________

Civil Status [ ] Single [ ] Married [ ] Widowed [ ] Legally Separated Preferred Billing Address: [ ] Home [ ] Office

CARD REPLACEMENT (A Replacement Fee will be charged to your account)

If Supplementary card is to be replaced, please indicate card number: ______ - ______ - ______ - ______
Reason: [ ] Defective Magnetic Strip [ ] Damaged (Cracked, Spoiled)
[ ] Correction in Name* [ ] Change in Name due to Change in Status*
(valid ID should be submitted) (supporting docs .i.e. marriage certificate should be submitted)

*New Name to Appear on Card

CARD REACTIVATION* CARD RENEWAL

Principal Card No. ______________________________
Suplementary Card No/s** ______________________________ Note: Supplementary cards will be renewed
together with the Principal Card. If you opt not to
______________________________ renew your Supplementary Card/s, you may
request for the cancellation of these cards.
*If card has been cancelled for more than a year, please fill up a new application
form and indicate cancelled Principal Card Number.
**Supplementary card/s will not be reactivated unless requested by Principal Cardholder

CREDIT LIMIT INCREASE / DECREASE

DEFERRED LIMIT INCREASE / DECREASE From To
Php _______________ Php _______________
[ ] Principal Account
USD _______________ USD _______________
[ ] Supplementary Card No. ____________________________

CARD UPGRADE*
[ ] From Classic to Gold Card [ ] From Gold to Classic Card
Credit Limits Php ____________________ Credit Limits Php ____________________
USD ____________________ USD ____________________
*Old card will be cancelled upon issuance of upgraded/downgraded card

CANCELLATION
[ ] Principal Card No. ______________________________ Effective [ ] Immediately
[ ] Supplementary Card No/s. ______________________________ [ ] Upon Expiry
______________________________
Reason ________________________________________________________________________

SUPPLEMENTARY CARD REQUEST

Supplementary Card Applicant No. 1 (Last Name, First Name Middle Name) Signature of Supplementary Cardholder

Relationship to Principal Cardholder __________________________ Sub-Limit Assignment: Php ____________& US$ ____________
Supplementary Card Applicant No. 2 (Last Name, First Name Middle Name) Signature of Supplementary Cardholder

Relationship to Principal Cardholder __________________________ Sub-Limit Assignment: Php ____________& US$ ____________

For Internet Use only

MODE OF PAYMENT
[ ] Pay to Bank
[ ] Peso Auto-Debit my Equicom Savings Bank Account No. ______________________ [ ] Full [ ] Minimum
[ ] Dollar Auto-Debit my Equicom Savings Bank Account No. ______________________ [ ] Full [ ] Minimum

PRINCIPAL CARDHOLDER INFORMATION

Name of Principal Cardholder
(Last name, First Name, Middle Name)

Equicom Savings Bank VISA Card Number

- - -
Home Phone Mobile Phone Email Address

Principal Cardholder’s Signature Date

FOR BANK USE ONLY
Verified By: Approved By: