Additional Request Form

S.No. ____________

Branch Date D D M M Y Y Y Y
Personal Details
Customer No.
Customer Name
Preferred Title Mr. Mrs. Ms. Dr. Other Mother’s First Name
Date of Birth D D M M Y Y Y Y Place of Birth Preferred Language English Sinhala Tamil
Telephone (Residence) Telephone (Office) Mobile
(Area Code) (Area Code)
NIC No. NIC Expiry Date D D M M Y Y Y Y Nationality
Marital Status Profession E-mail
Account Details
Existing Account Title
Existing Account No. New Account No.

Type of Account HBL Al Samarat Account (IE)* HBL Islamic High Yield FC Dep HYFID (IF)*
Term Deposit Accounts HBL Al Ziarat Account (IH)*

Current Accounts Current Account (IA) Other

(Please specify)

HBL Islamic Savings Account (IC) HBL Al-Irtifa Account (ID)*

Savings Accounts
HBL Al Mukhtar (IG)* Other

Foreign Currency Accounts (FCY) FC Current Account (IJ, IK, IL) HBL Islamic FC PLS Account (IM, IP, IQ) Other
Account (FCY)

Currency LKR USD EURO GBP Other

Particulars of Deposits
I/We hereby authorise the Bank to debit my/our Account No. and create the following deposit:
Period Amount (in figures) Rs./FCY
Amount (in words) Rupees/FCY
On Maturity: Encash and credit to Account No.
(Tick appropriate box)
Rollover for same tenor With Profit Without Profit
Credit Profit in Account No.

Profit Frequency (Please tick the appropriate box)

Monthly Quarterly Half Yearly Yearly Maturity

Service Request Kindly select the services you require

HBL DebitCard (For Individual/Joint & Sole Proprietorship Accounts only which are operated on the signature of any one singly/either or survivor)

Primary Applicant Name on Card

Joint/Supplementary Applicant Name on Card-1
Joint/Supplementary Applicant Name on Card-2
Joint/Supplementary Applicant Name on Card-3

Linking of additional accounts with HBL DebitCard

Kindly limit your name to 19 characters (Including spaces)
HBL DebitCard No. Please leave a blank box between names

Account No. Title of Account

Account No. Title of Account

Request for HBL DebitCard replacement(s) (Please strike out as applicable)

Please replace my/our existing card(s) due to loss/theft/damage/expired (For replacement, please write your HBL DebitCard number in the box below)
HBL Primary/Supplementary DebitCard No.

HBL PhoneBanking/HBL InternetBanking

E-mail Address (Please leave blank if provided above)

* Terms & Conditions Apply.

Customer Slip/Copy
We acknowledge receipt of your request for additional services/account S. No.

Date D D M M Y Y Y Y Authorised signature with

branch stamp
 Change of Address (Please record the undermentioned instruction(s)
I also hereby authorise the Bank to update my address across all delivery channels Home Address Permanent Address Office Address
Previous Address
New Address
City Post Code Tel. No. Fax No.
(Area Code) (Area Code)

HBL SMS Alerts Service

Mobile Number (Please leave blank if provided overleaf)

Stop Payment
Cheque No. from to Amount
Favouring Time instruction received and marked

Loss of Pay Order / Foreign Currency Demand Draft

Instrument No. Amount Date of Issue D D M M Y Y Y Y Date of Request D D M M Y Y Y Y
Favouring Counterfoil/Customer copy attached Yes No Time of Request
(Daily, Weekly, Fortnightly,
Standing Instructions
Monthly, Quarterly,
Amount Frequency Half Yearly, Yearly) Start Date D D M M Y Y Y Y Expiry Date D D M M Y Y Y Y
Beneficiary A/C No. Beneficiary Name
Balance Certificate
Please provide me the balance certificate as of date D D M M Y Y Y Y
Purpose

Statement of Account
Please provide me the statement of account for the period
Start Date D D M M Y Y Y Y End Date D D M M Y Y Y Y

Account Closure
I/We wish to close my/our account for reason
Cheque Book Returned Yes No Cheques from to
Locker Surrendered Yes No HBL DebitCard surrendered Yes No Debit
Card No.
Break Opening of Lockers / Safe Deposit Box (Due to loss of key)
Key of Locker No. allotted to me has been misplaced/lost. Please break open the locker and provide me with a new key.

Signature Update
Please update my new signature
on the account mentioned overleaf
(I have completed the specimen
signature card) New Signature New Signature New Signature New Signature
(Primary Applicant) (Joint Applicant 1) (Joint Applicant 2) (Joint Applicant 3)

Correction/Change in Account Title

Incorrect Account Title
Correct Account Title
(Maximum 35 characters)

Activation of Inactive Account

Please activate my account mentioned overleaf Copy of valid NIC/Passport submitted Reason for non-usage of account

Other Requests/Instructions

Authority
I/We authorise the above instructions and have read and understood the Terms & Conditions governing Bank Account(s) at HBL, a copy of which has already been supplied to me/us at
the time of Account opening. I/We agree to be bound by the Terms & Conditions and amendments which HBL may deem fit. I/We also authorise the Bank to debit my account with the
charges applicable for the above services as per current Schedule of Bank Charges.

Signature of Applicant(s)

Primary Applicant/ Joint Applicant 1/ Joint Applicant 2/ Joint Applicant 3/

Authorised Signature Authorised Signature Authorised Signature Authorised Signature

For Bank Use Only

Date Received D D M M Y Y Y Y Approved by Signature Verified

011-2444442 www.hbl.com/SriLanka