LAND BANK OF THE PHLIPPINES

Branch

LAND BANK CASH CARD ENROLLMENT FORM

HH ID: Date:
Please check the type of card being enrolled:

Cash Card Prepaid Card Individual Institution

Individual Regular (CUP/JCB/Master Card/Others, pls specify )

Institution Gift Card (CUP/JCB/Master Card/Others, pls specify )

Purchaser's Information

Purchaser's Name: With existing account with LBP Yes No

If yes, pls specify Acct. No/s.:
DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT Cash Card Number/s:

ADDITIONAL INFORMATION FOR WALK-IN INVIDUAL PURCHASER, AND CARDHOLDER OF INSTITUTIONAL PURCHASER:
Cardholder's Name (Applicable only for Gift Card purchased by an Institutional Customer): Gender:

Permanent Address: Zip Code:

Present Address: Zip Code:

Place of Birth: Date of Birth: Nationality: Mother's Maiden Name:

FILIPINO

Type of ID Presented: ID Number Presented: Profession: Source of Fund: TIN Number:

O1 DSWD-4Ps ID N/A 99 N/A

Name of Employer/Company/Business/School: Contact Number/s: (home/office/mobile): Gross Salary:

DSWD 931-81-01 1
Cardholder's Information
Cardholder's Name: Contact Number/s: Date of Birth:

Permanent Address: Zip Code: Relationship with the Purchaser:

Present Address: Zip Code:

Name to Appear on the Card (with maximum of 24 characters)

Amount of Fees/Charges to be paid: Mode of Payment:

Cash Debit from Account

P
(Initial Cost of the Card) Account No.
I/We hereby certify that the above information is true and correct:

Signature Over Printed Name Signature Over Printed Name

of Purchaser/Applicant/Authorized Signatory of Purchaser/Applicant/Authorized Signatory

FOR BANK'S USE ONLY

Processed by: Checked by: Approved by:

Customer Associate/NAC BOO/BSO Branch Head

Date: Date: Date:

CASH CARD/PIN CLAIM STUB

MAILER
Card Number: Card Holder's Name: Purchaser's Name: Date:

Cash Card Released by: PIN Mailer Released by: Approved for Release: Card/PIN Mailer Received by:

Card Custodian PIN Mailer Custodian Branch Head/BOO/BSO Signature Over Printed Name
Date: Date: Date: of Purchaser/Cardholder
Reminders:
-You may claim your Cash Card after seven (7) days for Metro Manila Branches, and 15 banking days for Provincial Branches.
-Unclaimed Cash Card/PIN Mailer shall be perforated after 120 calendar days (for CCT)/30 calendar days (regular) from issuance/re-issuance
-Please sign your Cash Card immediately
Validation Print (if debited from deposit account):