Branch: AGUIRRE BRANCH

CIF No. _____________________

Date: _______________________

K i ndl y a cco m pli s h w i t h a ccura t e a nd la te s t i nfo rm at i o n, us i ng bl o ck le t te rs . D o no t l ea v e a ny fi e l d bla nk . Indi ca t e N/ A i f No t Appl i ca ble .

Customer Name: (N o acr ony m s or abbr e v i at i on) UCPB Connect Username:

Email Address for ONLINE TRANSACTIONS: Mobile Phone Number for ONLINE
TRANSACTIONS:

REQUESTS:
 ENROLL THE FOLLOWING ACCCOUNTS TO UCPB CONNECT: Account Number/s:
*You can enroll more accounts later

 UNBLOCK MY UCPB CONNECT ID:

- I still remember my password but I have been locked out due to
previous incorrect password entries.
 RESET MY UCPB LOG-IN PASSWORD:
- I don’t remember my password anymore
- A new password will be sent to my registered e-mail address

 UPDATE MY E-MAIL & MOBILE NUMBER IN UCPB CONECT From:

- I already updated it in the “Edit Customer Profile” in UCPB Connect
- I will fill-up a UCPB Client Information Sheet. To:
By signing below, I hereby certify and attest to the fact that all information represented and given by me are true and
correct. I shall promptly communicate to the Bank any changes in the foregoing information. I hereby authorize the
Bank to verify and investigate any and all information given by me, as the Bank may deem appropriate.

I further certify that I have read and understood the UCPB Connect Terms and Conditions and hereby accept them.

Printed Name over Signature Date

Signature Verified by: Activated / Enrolled by: Approved by:

Senior Teller Date Branch Operations Officer Date Branch Manager Date