Additional Request Form

S.No. ____________

Branch Branch Code Date D D M M Y Y Y Y

Account Officer

Personal Details
Customer No.
Customer Name
Preferred Title Mr. Mrs. Ms. Dr. Other Mother’s First Name
Father’s / Husband’s Name TIN Residence Country Nationality
Date of Birth D D M M Y Y Y Y Place/Country of Birth Preferred Language English isxy, jkpo;
Telephone (Residence) Telephone (Office) Mobile
(Area Code) (Area Code)
NIC / Passport No. Expiry Date D D M M Y Y Y Y Date of Issue D D M M Y Y Y Y

Dual Nationality* Country of Tax Residency

Overseas Address

Foreign Tax No. / USA TIN Overseas Res. Card No. Overseas Contact No.

Marital Status Profession E-mail

Have you given Power of Attorney to any person residing overseas? Yes No Attorney Add.
Have you renounced your Foreign Citizenship? Yes No W8BEN / W9 USA Tax forms submitted? Yes No Please provide date D D M M Y Y Y Y
*Please provide country specific documentation where dual nationality applies

Additional Details (For Un-listed / Private / Public limited / Multinational / Partnership)

If the Entity has more than 50% of passive income (i.e. Divident, Rent, Royalty, Interest) please submit duly completed ‘W8BEN-E Form’. And, if the Entity has US person as
shareholder(s) holding more than 10% shares then please provide below details and submit duly completed W-9 form.
Name of Person % of Ownership Date of Submission of W-9 D D M M Y Y Y Y
Name of Person % of Ownership Date of Submission of W-9 D D M M Y Y Y Y
Date of Submission of W8BEN-E D D M M Y Y Y Y
Note: In case of more shareholders attach similar details

Account Details
Existing Account Title
Existing Account/IBAN No.
New Account /IBAN No.

New Account Request

Type of Account
(Please tick appropriate box)

Current Accounts Current Account* (CA) HBL Freedom Account* (C4) Business Value Account* (CE) Other (Please specify)

Savings Accounts HBL Savings Account (EC) Daily Interest Account* (ED) HBL Value Account* (EA)

Staff Savings Account (ES) Other (Please specify)

Foreign Currency FC Savings Account (EN, EP, EQ) Other

FC Current Account (CK, CL, CM) (Please specify)
Accounts (FC)

Loan Account Overdraft (KA) Other (Please specify)

* Kindly also fill the Product Specific Apllication Form with related terms and conditions

Currency LKR USD EURO GBP Other

Particulars of Fixed/ Term Deposit

I/We hereby authorise the Bank to debit my/our Account / IBAN No.
and create the following deposit: Period Amount (in figures) Rs./FCY
Amount (in words) Rupees/FCY
On Maturity: Encash and credit to Account/IBAN No.
(Tick appropriate box)
Rollover for same tenor With Interest Without Interest
Credit Interest in Account/ IBAN No.
Interest Frequency (Please tick the appropriate box)

Monthly Quarterly Half Yearly Yearly Maturity

Service Request (Kindly select the services you require)
HBL VISA DebitCard For Individual and Joint Accounts only which are operated with the single signing mandate (self / anyone singly / either or survivor)

Primary Applicant Name on Card

Joint/Supplementary Applicant Name on Card-1
Joint/Supplementary Applicant Name on Card-2
Joint/Supplementary Applicant Name on Card-3
Note: For supplementary debit card, please complete the supplementary debit card application form
Linking of additional accounts with HBL VISA DebitCard
Kindly limit your name to 19 characters (Including spaces)
HBL DebitCard No. Please leave a blank box between names

Account/ IBAN No. A/C Title

Account/ IBAN No. A/C Title

Customer Slip/Copy
We acknowledge receipt of your request for additional services/account/IBAN: S. No.

Date D D M M Y Y Y Y Authorised signature with

branch stamp
 Request for HBL DebitCard replacement(s) (Please strike out as applicable) Card Cancellation PIN Replacement
Please replace my/our existing card(s) due to loss/theft/damage/expired
HBL Primary/Supplementary DebitCard No.

HBL PhoneBanking / HBL InternetBanking / E-statement (Please strike out as applicable) HBL SMS Alert Service
E-mail Address Mobile No.

Change of Address Please record the undermentioned instruction(s)

I also hereby authorise the Bank to update my address across all delivery channels Home Address Permanent Address Office Address
New Address City
Country Post Code Tel. No. Fax No.
(Area Code) (Area Code)

Change of Correspondent / Mailing Address Please record the undermentioned instruction(s)

Home Address Permanent Address Office Address
I also hereby authorise the Bank to update my address across all delivery channels
New Address City
Country Post Code Tel. No. Fax No.
(Area Code) (Area Code)

Stop Payment
Cheque No. from to Amount
Favouring Time instruction received and marked

Loss of Pay Order / Foreign Currency Demand Draft

Instrument No. Amount Date of Issue D D M M Y Y Y Y Date of Request D D M M Y Y Y Y
Favouring Counterfoil/Customer copy attached Yes No Time of Request

Standing Instructions (Daily, Weekly, Fortnightly,

Monthly, Quarterly,
Amount Frequency Half Yearly, Yearly) Start Date D D M M Y Y Y Y Expiry Date D D M M Y Y Y Y
Beneficiary A/C/ IBAN No. Beneficiary Name
Balance Certificate
Please provide me the balance certificate as of date D D M M Y Y Y Y
Purpose

Duplicate Statement of Account

Please provide me the duplicate statement of account for the following Account/IBAN and debit the charges from this account
Account/ IBAN No.
Start Date D D M M Y Y Y Y End Date D D M M Y Y Y Y

Account Closure
I/We wish to close my/our account for reason
Cheque book returned Yes No Cheque No. from to
Locker surrendered Yes No HBL VISA DebitCard surrendered Yes No Debit
Card No.
Break Opening of Lockers / Safe Deposit Box (Due to loss of key) Key No. allotted to me for Locker No. has been misplaced/lost.
Please break and open the locker and provide me with a new key
Signature Update
Please update my/our new signature
on the account mentioned overleaf
(I/ We have completed and submitted the specimen
signature card) New Signature New Signature New Signature New Signature
(Primary Applicant) (Joint Applicant 1) (Joint Applicant 2) (Joint Applicant 3)

Correction/Change in Account Title

Incorrect Account Title
Correct Account Title
(Maximum 30 characters)

Activation of In-active Account

Please activate my account mentioned overleaf Copy of valid NIC/Passport submitted Reason for non-usage of account

Other Requests/Instructions

Authority
I/We authorise the above instructions and have read and understood the Terms & Conditions governing Bank Account(s) as well as corresponding product(s) at HBL, a copy of which has
already been supplied to me/us. I/We agree to be bound by the Terms & Conditions and amendments which HBL may deem fit. I/We also authorise the Bank to debit my/our account
with the charges applicable for the above services as per current Schedule of Bank Charges, where applicable.
Signature of Applicant(s)

Primary Applicant/ Joint Applicant 1/ Joint Applicant 2/ Joint Applicant 3/

Authorised Signature Authorised Signature Authorised Signature Authorised Signature

For Bank Use Only

Current/ Saving/ Term Deposit Account Opening HBL SMS Alerts Service Account Closure
HBL DebitCard Change of Correspondent / Mailing Address Signature Update
Linking of additional accounts with HBL DebitCard Stop Payment Correction/Change in Account Title
Request for HBL DebitCard replacement(s) Loss of Pay Order / Foreign Currency Demand Draft Activation of Inactive Account
HBL PhoneBanking/HBL InternetBanking Standing Instructions Other Requests/Instructions
Change of Address Balance Certificate
Break Opening of Lockers / Safe Deposit Box Statement of Account (Please specify)

Approved by Signature verified by

Date Received D D M M Y Y Y Y P.A.No. P.A.No.

011-2444442 www.hbl.com/SriLanka