CUSTOMER REQUEST FORM (CRF) QLANDBANK

Branch
Name (Last Name,First Name,MiddleInitial): Account No.: Control No:.

Statement of Account/Bank Certification

D Snapshot D Bank Statement (Re-printing) D Bank Certification of Deposit Balance
Purpose Period
Covered
Re-orderof Checkbook
□ □
No.of Booklet/s:
Personal commercial 0 MDS
For Authorized Representative:
Thisis to authorize whosesignatureappears below. toacknowledge receipt of the
above document.
f't"l
Authorized Representative «I>
(Signature overPrintedName)
D Stop PaymentOrder (SPO) O Cancellationof SPO
Check No.From: To:
Amount: Date of
Check: Payee: Reason:
Date/Time Received: Expiry Date:
Note:This request issubject to theTerms andCondition stated at the back of this
form.
Mode of Payment: O cash 0 Debit Account No.
;:::

□ HoldFund 0 Account Balance

s·
"<'
D Release of Hold 0 Specific Amount:
! !! .
a :
"g':
Purpose: :::,

For iAccess (Existing enrolled accounts only)

D Maintenance
0 Unlocking of iAccess ID 0 Enabling 0 Deletion of iAccess
ID
0 Password Resetting 0 Reactivation/Disabling
0 Updating of Profile Details: New Data:
D FundTransfer
Account No. Source Destination Addition Deletion
D □D D D
D
□
ThirdParty Destination
□ Account No.
D D
Account Name
□

Note:This issubject tothesameTerms andConditions stated intheiAccess Enrollment andMaintenace Agreement Form.
Authorized Signatory/ies

f','\
(Signature overPrintedName) (Signature over PrintedName)
FOR BANK'S USE ONLY
Processed by: Checked/Approved by:

Customer Associate-NAC/Dat e
BOO/BSO or
(SignatrueoverPrinted Name)
BranchHead
(Signatrueover October 2017
PrintedName)

CRF CLAIM STUB

Name (Last Name,FirstName, Account No.: Control No.:
MiddleInitial):

Approved forrelease by: Released by: Received by:

Branch Head BOO/BSO or Branch Customer/AuthorizedRepresnetative

(Signatuer overPrinted Name) Head (Signature overPrinted Name)
(SignatureoverPrintedName)