TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL

SENDER NAME: SENDER NAME:

RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
AGENT'S SIGNATURE: AGENT'S SIGNATURE:
TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL
SENDER NAME: SENDER NAME:
RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
AGENT'S SIGNATURE: AGENT'S SIGNATURE:
TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL
SENDER NAME: SENDER NAME:
RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
AGENT'S SIGNATURE: AGENT'S SIGNATURE:
TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL
SENDER NAME: SENDER NAME:
RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL
SENDER NAME: SENDER NAME:
RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL
SENDER NAME: SENDER NAME:
RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL TRANSACTION TYPE: SENDING PAYOUT AMEND REFUND CANCEL
SENDER NAME: SENDER NAME:
RECEIVER NAME: RECEIVER NAME:
CONTACT NUM: CONTACT NUM:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL/ACCNT NO: CONTROL/ACCNT NO:
DATE: DATE:
CLIENT'S SIGNATURE: CLIENT'S SIGNATURE:
TRANSACTION SENDING PAYOUT AMEND REFUNDCANCEL TRANSACTIONSENDING PAYOUTAMEND REFUND CANCEL
SENDER : SENDER :
RECEIVER RECEIVER
CONTACT #: CONTACT #:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL # CONTROL #
DATE: DATE:
SIGNATURE: SIGNATURE:
AGENT'S SIGNA AGENT'S SIGN

TRANSACTION SENDING PAYOUT AMEND REFUNDCANCEL TRANSACTIONSENDING PAYOUTAMEND REFUND CANCEL

SENDER : SENDER :
RECEIVER RECEIVER
CONTACT #: CONTACT #:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL # CONTROL #
DATE: DATE:
SIGNATURE: SIGNATURE:
AGENT'S SIGNA AGENT'S SIGN

TRANSACTION SENDING PAYOUT AMEND REFUND TRANSACTIONSENDING PAYOUTAMEND REFUND CANCEL

SENDER : SENDER :
RECEIVER RECEIVER
CONTACT #: CONTACT #:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL # CONTROL #
DATE: DATE:
SIGNATURE: SIGNATURE:
AGENT'S SIGNA AGENT'S SIGN

TRANSACTION SENDING PAYOUT AMEND REFUNDCANCEL TRANSACTIONSENDING PAYOUTAMEND REFUND CANCEL

SENDER : SENDER :
RECEIVER RECEIVER
CONTACT #: CONTACT #:
AMOUNT: PHP BDAY: AMOUNT: PHP BDAY:
CONTROL # CONTROL #
DATE: DATE:
SIGNATURE: SIGNATURE:
AGENT'S SIGNA AGENT'S SIGN
 AUTHORIZED AGENT - CLIENT INFORMATION SHEET
CLIENT'S NAME: First Name: Middle Name: Last Name:
PRESENT ADDRESS:
PERMANENT ADDRESS: Same as present address
MOBILE/LANDLINE NO: SOURCES OF FUNDS:
DATE OF BIRTH: Salary/Wage/Commision Retirement/Pension Fund Business

PLACE OF BIRTH: Regular Remittance/Allowance Bank Deposits/Placements/Investments Others:________

NATIONALITY: EMPLOYMENT STATUS:

ID PRESENTED: Employed Self Employed Unemployed
ID NUMBER: Name of Employer: __________________Name of Business: _________________
BENEFICIARY DETAILS: Nature of Work: ____________________Nature of Business: ________________
Name: ARE YOU A GOVERNMENT EMPLOYEE? YES NO
Present Address: If yes, indicate the position and office: __________________________________
Date of Birth: DO YOU HAVE IMMEDIATE RELATIVE WORKING IN THE GOVERNMENT? YES NO
Place of Birth: IF YES, Name of Government Employee: __________________________________
Source of Funds: Position and Office: __________________________________________________
Nature of Work: Relationship: Spouse Child Parent Sibling
DATA PRIVACY AGREEMENT & CLIENT CONSENT DECLARATION
I understand that the information collected, to be processd and retained shall be for the following purposes: client identification; profiling; direct marketing and cross-selling of products; and compliance

to BSP rules, AMLA and such other purposes that may required or allowed by law. I have been informed that I have the option not to give the foregoing information, in which case I understand that my
transaction will not be processed. I have also been informed that I can make corrections to any inaccurate or deficient information and that I have an option to withdraw my consent prior to processing

of my transaction by emailing Cebuana Lhuillier at cebuanacares@pjlhuillier.com or calling Telephone Numbers 779-9800 PLDT/ 759-9800 GLOBELINES.

I hereby certify that the foregoing information are freely and voluntarily given and are true and correct to the best of my knowledge. Further, I hereby authorize Cebuana Lhuillier to disclose to its partners,

agents or other clients my above information to aid in any and all investigations that may be initiated on account of, or in relation to any concerns that may arise out of this transaction.
___________________________________________ ______________________________________
CLIENT SIGNATURE OVER PRINTED NAME VERIFIED BY: AUTHORIZED AGENT

AUTHORIZED AGENT - CLIENT INFORMATION SHEET

CLIENT'S NAME: First Name: Middle Name: Last Name:
PRESENT ADDRESS:
PERMANENT ADDRESS: Same as present address
MOBILE/LANDLINE NO: SOURCES OF FUNDS:
DATE OF BIRTH: Salary/Wage/Commision Retirement/Pension Fund Business

PLACE OF BIRTH: Regular Remittance/Allowance Bank Deposits/Placements/Investments Others:________

NATIONALITY: EMPLOYMENT STATUS:

ID PRESENTED: Employed Self Employed Unemployed
ID NUMBER: Name of Employer: __________________Name of Business: _________________
BENEFICIARY DETAILS: Nature of Work: ____________________Nature of Business: ________________
Name: ARE YOU A GOVERNMENT EMPLOYEE? YES NO
Present Address: If yes, indicate the position and office: __________________________________
Date of Birth: DO YOU HAVE IMMEDIATE RELATIVE WORKING IN THE GOVERNMENT? YES NO
Place of Birth: IF YES, Name of Government Employee: __________________________________
Source of Funds: Position and Office: __________________________________________________
Nature of Work: Relationship: Spouse Child Parent Sibling
DATA PRIVACY AGREEMENT & CLIENT CONSENT DECLARATION
I understand that the information collected, to be processd and retained shall be for the following purposes: client identification; profiling; direct marketing and cross-selling of products; and compliance

to BSP rules, AMLA and such other purposes that may required or allowed by law. I have been informed that I have the option not to give the foregoing information, in which case I understand that my
transaction will not be processed. I have also been informed that I can make corrections to any inaccurate or deficient information and that I have an option to withdraw my consent prior to processing

of my transaction by emailing Cebuana Lhuillier at cebuanacares@pjlhuillier.com or calling Telephone Numbers 779-9800 PLDT/ 759-9800 GLOBELINES.

I hereby certify that the foregoing information are freely and voluntarily given and are true and correct to the best of my knowledge. Further, I hereby authorize Cebuana Lhuillier to disclose to its partners,

agents or other clients my above information to aid in any and all investigations that may be initiated on account of, or in relation to any concerns that may arise out of this transaction.
___________________________________________ ______________________________________
CLIENT SIGNATURE OVER PRINTED NAME VERIFIED BY: AUTHORIZED AGENT