LIVERPOOL BANK LIVERPOOL BANK

Account Form Account Form

1. First Name : ___________________ 1. First Name : ___________________
2. Last Name : ___________________ 2. Last Name : ___________________
3. Gender : Male/Female 3. Gender : Male/Female
4. Date of Birth : __________________ 4. Date of Birth : __________________
5. Place of Birth : __________________ 5. Place of Birth : __________________
6. Address : __________________ 6. Address : __________________
7. Phone Number : __________________ 7. Phone Number : __________________
8. Mother’s Maiden Name : __________________ 8. Mother’s Maiden Name : __________________
9. Marital Status : Single ( ) 9. Marital Status : Single ( )
Married ( ) Married ( )
Divorced ( ) Divorced ( )
10. Types of Account: 10. Types of Account:
Checking Account ( ) Checking Account ( )
Savings Account ( ) Savings Account ( )

11. First Deposit: Rp. _________________ 11. First Deposit: __________________

Signature:
Signature:

Customer Service: ___________________________

Customer Service: ___________________________

Date: _________________________________
Date: _________________________________