Request for a BSP PacifiCard

BANK SOUTH PACIFIC

CIF # 1212891

I/We hereby apply a BSP PacifiCard. The Bank is hereby authorised a charge to the account(s)
nominated below any debits and charges initiated/incurred by me/us by the use of the Card
issued pursuant to this application in any Electronic Funds Device and approved by the Bank
from time to time. I/We acknowledge that should this application be approved the Card which
issues will be governed by Conditions of Use which will accompany the Card.

Customer Name MARIO KAONI

GHOTUNI VILLAGE
Mailing Address RUAVATU PSS
GUADALCANAL PROVINCE

Residential Tel No Business Tel No

The Bank South Pacific PacifiCard will provide access to my accounts as follows:

Cheque Account Number 2000813283

Account Branch

Advantage Account Number

Account Branch

Signature Date / /

New Card #
OFFICE USE ONLY

Signature Verified

All details Appointed

Date / /
confirmed Officer

MCD(0515)