APPLICATION FOR

o PURCHASE OF FOREIGN EXCHANGE

6BPI ~ Bank of the Philippine Islands

o BPI Family Savings Bank

o TELEGRAPHIC TRANSFER Peso/Foreign
o DEMAND DRAFT Peso/Foreign
,.....e:r MANAGER'S CHECK 0 TRAVELLER'S CHECK

PAYEEIBENFICIARY RECEIVING/BENEFICIARY BANK DETAILS:

BANK NAME
FOR TELEGRAPHIC TRANSFER:BENE'S ACCOUNT NUMBER or
ADDRESS
International Bank Account Numbe.;IBAN) lor EURO BANK CODE(SWIFT/FEDICHIPS UID/OTHERS)
REMITIER TO BENEFICIARY INFO (maximum 210 characters)

o CASHIBPI CHK. NO.

o DEBIT MY/OUR
POSTAGE/CABLE CIANo. I
DOCSTAMPS SIANo.
TOTAL
TELLER'S VALIDATION

~47 .. 4 &i~ C,
208 7$:1~8' 8t04 PHP

By signing below, lIWe hereby, If and when applicable:

(I) Declare under the penalties of perjury that my/our co-depositor is/are still living.
(ii) Authorize the person whose signature appears below to receive MCIDDITC on my/our behalf
(ill)Authorize the Bank to debtt my/our account for the MCIDDITCm applied forlbought subject to the conditions hereof to which I/We agree:
CONDITIONS FOR THE ISSUANCE OF MANAGER'S CHECKS AND
REMITTANCE OF FUNDS BY DRAFT, MAIL OR TELEGRAPHIC TRANSFER
Payment of the draft/check issued herein Is qualified by and condttioned upon receipt by the addressee branch/correspondent of the correlative adviceflnstruction from the issuing office,
Ramittance under this application shall be made by the Bank according to tts customary procedure; and for this purpose. tt shall have absoluta discretion. in behalf of the applicant. to avail of
the services of any correspondents, agents, sub-agents, or other instrumentality. but in no case shall this Bank or any of its corraspondents, agents. sub-agents. etc., be Iiabla for mutilations,
Intemuptions, defaulls. errors, non-transmission mishaps. accidants, or dalays that might occur in the mails or postal sarvice, or due to the act, omission or negligence of any telegraphic. cable or
wireless company. or any employee or amployees thereof. or through any causa beyond the control of this Bank or Its correspondents. .
This Bank may send any message relative to this remittance in explicillanguage, code or cipher, through any talegraphic, cable or radio establishment that tt might choose; but in no case shall
this Bank be Iiabla for errors. neglects, or defaulls that might be committed in the transmission of the relative message. or in the misinterprEtation thereof by he partyfles receiving it.
Refund, if nequested by the applicant. may be mada at tha discretion of this Bank, but only if, and after. this Bank has received confirmation of affective ncellaticn of the remittance. and/or all
copies 01 drafts that have been issued, if any. are surrendered; and, in case of funds, already converted, refund may be made at the rate which this Bank ay fix, less all expenses incurred by it. tts
correspondents and agents. ~/"l
In case of ,lOSSor deslructio~}'f the originalls and or any draft/s or check/s, this Bank reserves the right to require, for its protection. a bond of inde ity ~y other sufficient security
acceptable to iI. before iSSUInga re ce••. ment for the lost inslrumenlls or refund of the value thereof.

JOn ~ on f f/Y(j Gmt"

Customer's Signature Over Pl'lnted Name
NOTARIZATION FOR AMOUNT IN EXCESS OF US 30,000.00
REPUBLIC OF THE PHILIPPINES )
)5,5,
Subscribed and sworn to before me in , on this day of , affiant who is
personally known to me and to me known to be the same person who executed the foregoing instrument. exhibited to me his/her Community Tax Certificate No. _
issued al on ; and/or who was identified by me through competent evidence of identity to be the same person who
executed the foregoing instrument, exhibited to me his/her Government issue 10 No. issued at oo _
acknowledged to me that the same i~ his/herfnee and voluntary act and deed.
Notary Public
My Commission expire on _
RISK LEVEL - COD Commission Serial No.
Place of COmmission
_
_
~ 0 MEDIUM HIGH OfficeAddress _
Roll No. IBP No. _
NORMAL AVERAGE E lANCED PTRNo, PlaC'e__ ---- __ Date _
NDB/OFAC CHECKED BY: