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    ATM Card Replacement Form

    Uploaded by

    Ailene
    The client is requesting a replacement card due to their card being lost. They provide their name, address, date of birth, phone number and email. Their account number and name are also listed. They acknowledge that any transactions made before reporting the card lost will be their responsibility. They agree to pay processing fees for the replacement card. Bank personnel verify the client's identity and signature before approving the replacement card request.

    Copyright:

    © All Rights Reserved
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    ATM Card Replacement Form

    Uploaded by

    Ailene
    362 views1 page
    The client is requesting a replacement card due to their card being lost. They provide their name, address, date of birth, phone number and email. Their account number and name are also listed. They acknowledge that any transactions made before reporting the card lost will be their responsibility. They agree to pay processing fees for the replacement card. Bank personnel verify the client's identity and signature before approving the replacement card request.

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    The client is requesting a replacement card due to their card being lost. They provide their name, address, date of birth, phone number and email. Their account number and name are also listed. They acknowledge that any transactions made before reporting the card lost will be their responsibility. They agree to pay processing fees for the replacement card. Bank personnel verify the client's identity and signature before approving the replacement card request.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    362 views1 page

    ATM Card Replacement Form

    Uploaded by

    Ailene
    The client is requesting a replacement card due to their card being lost. They provide their name, address, date of birth, phone number and email. Their account number and name are also listed. They acknowledge that any transactions made before reporting the card lost will be their responsibility. They agree to pay processing fees for the replacement card. Bank personnel verify the client's identity and signature before approving the replacement card request.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Exhibit 1

    CARD REPLACEMENT FORM


    BRANCH: REQUEST DATE:

    CLIENT INFORMATION
    NAME OF CLIENT (LAST, FIRST, MIDDLE):

    ADDRESS:

    DATE OF BIRTH: TELEPHONE/MOBILE NUMBER: EMAIL ADDRESS:

    REQUEST DETAILS
    ACCOUNT NUMBER: ACCOUNT NAME: CARD NUMBER FOR REPLACEMENT:

    REASON FOR REPLACEMENT:

    Lost Captured Upgrade to MasterCard Others


    (Pls. specify)
    Stolen Place: ________________________ Forgot PIN

    Damaged/Mutilated Time: _________________________ Change of Name to:

    CUSTOMERS ACKNOWLEDGEMENT
    I hereby affirm that the foregoing facts and information as stated by me in this application are true and correct. I hereby bind myself to immediately
    surrender my Card which has been reported as lost in the event that the same is found. Transaction effected within 24-hours from the time I reported
    the loss shall be for my account.

    That the money represented by the balance in the account is my/our personal property, and that I/we have made no assignment, transfer or pledge
    thereof or in any manner negotiated the same with other parties.

    That I/we hereby hold Philippine National Bank free and harmless from any loss or damage that it may incur by reason of or in connection with the
    issuance of a new ATM Card/ Debit Card/ Cash Card.

    I agree to DEBIT MY ACCOUNT THE AMOUNT OF _____________________________________ for the processing fees or for any service
    charge imposed for the replacement of a NEW ATM Card/ Debit Card/ Cash Card.

    PRINTED NAME / SIGNATURE OF CARDHOLDER DATE SIGNED

    FOR PNB USE ONLY


    ID’s PRESENTED: PROCESSED BY / DATE: SIGNATURE VERIFIED BY / DATE: APPROVED BY / DATE:

    SIGNATURE OVER PRINTED NAME/ DATE


    SIGNATURE OVER PRINTED NAME / DATE SIGNATURE OVER PRINTED NAME/ DATE

    CARD AND PIN CONFIRMATION


    NEW CARD NUMBER: CARD ISSUED BY / DATE: PIN ISSUED BY / DATE:

    SIGNATURE OVER PRINTED NAME / DATE SIGNATURE OVER PRINTED NAME / DATE

    CARD AND PIN RECEIVED BY:

    PRINTED NAME / SIGNATURE OF CARDHOLDER DATE SIGNED

    Form No. ATM002

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