REVISED NOVEMBER 2015

CLIENT INFORMATION AND SPECIMEN SIGNATURE CARD (CISSC)

(DEPOSIT ACCOUNT) INDIVIDUAL
Customer No.
CUSTOMER
(continuation) FINANCIAL INFORMATION OF DEPOSITOR
TFyOpRe SCOodLeE: PPeRrOsoPnRaIlETORSHIPSuObN-tLyYpe code: 10 - Individual 20 - Sole Proprietorship
Business Name: PERSONAL INFORMATION
First Name (include name suffix: Sr., Jr., III, IV) Middle Name Last Name

Business Address ZIP Code Country

Nickname Nationality

P r e s e n t Ad d r e s s ( N o ./S t re e t ,S u b d .,B r gy./Dist./Mu n i c ip a li t y /C it y, P ro vi nc e )

B u s in e s s P h o n e ( A re a C o d e + T e l. N o .) D a t e E s t a b lis h e d (m m / d d/yyyy) Years in Business
C o un t r y ZIP Code
N o . o f E mployees

PelarcmeaonfeRnteAgidsdtrraetsiosn( No./Street,Subd.,BrgRy.e/Dgiissttr.a/MtiounniDciaptaelity/City,Province) Registration Number CouRntergy istering

Agency Z(CIPDAC,oDdeTI, SEC, etc.)

U.S. Address (if applicable) NATURE OF WORK/BUSINESS/ECONOMIC ACTIVITY ZIP Code

0100 - Agriculture, Hunting and Forestry 0800 - Hotel and Restaurant 1600 - Other Community, Social and Personal
Services 0200 - Fishing 0900 - Transportation (e.g.,Individual
Tax (TIN) + Tel. No.)
Service Provider)
Identification Number Residential Phone (Area Code Mobile Phone No.
0300 - Mining and Quarrying 1000 - Financial Intermediation 1700 - Private Household with Employed Persons
0400 - Manufacturing 1100 - Real Estate 1204 - Jewelry/ Precious Stones Dealer
U.S. S05o0c0ial- SEelervcitcreiciNtyu, mGbaesr a(SndSNW)aotreIrnSduivpidpulyal Tax Iden1t2if0ic0a-tioRneNntuinmgbaenrd(ITBIuNs)i,nief sasppAlcictiavbitliees 1005
-UF.oSr.ePighnoEnxec(hAarnegaeCDoedaele+r/MTeoln. eNyoC.)hanger/Remittance Agent 0600 - Construction 1400 -
Education 0021 - Others (pls. specify)
0700 - Wholesale and Retail Trade 1500 - Health and Social Work
PLirsotfoefsscoiomnpanies where depositor is a Directore/O-Mffiaciel rA/Sdtdorcekshsolder Length of Stay in the US

Current Yr Last Yr 2 Yrs Prior

Valid IDs Presented :

Existing AcAcCoRunNtso.W(FitohrOFtohreerigBnaNnkastionals)
Existing Accounts WitShSLSBPNo. Passport No.

Bank / Branch name Type of Account

Company ID No. GSIS No. Voter's ID No. Others
SA/ATM Trust Treasury
Source oCf FAu/AnTdsM: Loans 30 - BusinessCredit Card 60 - Other Remittance Gender: M F Civil Status: Separated

10 - S alary/Honoraria
T D Trade 40 - Pension 99 - Others
Individual (pls. (J)
(I)/Joint specify) Own Nationality
3rd Party Single
Source Destination Widowed
20 - Interest/Commission 50 - Overseas Filipino Remittance Married Divorced
PHONE ACCESS & iAccess ENROLLMENT
Date of Birth (mmddyyyy) Place of Birth No. of Children Mother's Maiden Name (First Name, Middle Name, Last Name)
Request for enrollment iAccess Phone Access Others (pls. specify)

Account Number Account Type* Account** Fund Transfer**

Bills Payment
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 ( NoM./Setrrceheat,nSt/uAbgde.,nBcrygy./Dist./Municipality/City,Province) Subscriber's Name ZIP Code

RefereCnocuenNtryumber*

FINANCIAL INFORMATION OF DEPOSITOR

Employer's Name Employment Start Date Job Title
*For verification of your reference number, please present your latest Billing Statement from your merchant.
Note: Please indicate "NOT APPLICABLE" or "NA" for fields with no applicable data and "Nothing Follows" immediately after the last item.
Validated/Assessed/Authenticated
Employer's ZIP Code
BE [ Address
] RBE ( No./Street,Subd.,Brgy./Dist./Municipality/City,Province)
[ ] Name of BE and Opened By:
I certify that the above information are true and correct.

Occupation M o n th ly G r o ss I nc o m e
Signatu r e O v er P r in te d N a m e
1 - Employed 3 - Overseas Filipino Worker 1 - Php 30,000.00 & Below 3 - Php 50,000.01 - 100,000 5 - Over Php 500,000
FOR BANK USE ONLY
2 - Self-employed 4 - Retired 5 - Others (pls. specify) 2 - Php 30,000.01 - 50,000 4 - Php 100, 000.01 - 500,000
Please put check () and indicate details, whenever applicable Approved By:
SPECIMEN SIGNATURE CARD
APcCcoun[t Nam] e WPR [ ] Name of PC
Account Type OFC [ ] Match
[ ] No Match
Signature Over Printed Name Signature Over Printed Name
FATF [ ] Match [ ] No Match Initial Deposit Date Opened
AcCcPoRunRt PNouimntbse[r : ] [ ] NR [ ] HR [ ]
LR DATE : DATE :
Cash
Date Updated
ATM CARD/PASSBOOK/CHECKBOOK ACKCNhOecWk LEDGEMENT SECTION
APPROVED FOR RELEASE: RELEASED BY: RECEIVED BY:

Customer Associate/Date1/Time Immediate Supervisor/Alternate Signature over printed name

PIN MAILER ACKNOWLEDGEMENT SECTION

PLEASE ATTACH RELEASED BY: RECEIVED BY:
ID PICTURE
L
2

LAND BANK OF THE PHILIPPINESBranch

(CLIENT INFORMATION AND SPECIMEN SIGNATURE CARD (DEPOSIT)) 11” X 7” 12-02-2015 / KATHRYN
Head/Alternate/Date/Time /JO
Signature 2015printed
over / LANDBANK
name CLIENT INFORMATION AND
SPECIMEN CLASNODNBOA.N1K24O0F6 THE PHILIPPINES (CLIENT INFORMATION AND SPECIMEN SIGNATURE CARD (DEPOSIT)) 11” X 7” 07-02-2015 Left / KATHRYN /JO 2015 / LANDBANK
Thumbmark CLIENT
Right Thumbmark
INFORMATION AND SPECIMEN CSO NO. 10320 JO NO. 2015-00954S