KHÁCH HÀNG CÁ NHÂN/CUSTOMER

Mã Khách hàng/Customer code

Ngày hiệu lực/Effective date

PHIẾU ĐĂNG KÝ THÔNG TIN KHÁCH HÀNG CÁ NHÂN

CUSTOMER INFORMATION FORM

THOÂNG TIN CUÛA KHAÙCH HAØNG (CUSTOMER’S INFORMATION)

Quyù khaùch vui loøng ñieàn ñaày ñuû thoâng tin trong muïc naøy. (Please complete all fields)

Teân khaùch haøng (Customer’s name): ....................................................................................................................................................................................................................

Ngaøy sinh (Date of birth): ............ / .......... / ................... Nơi sinh (Place of birth): ............................................. Giôùi tính (Gender): Nam (Male) Nöõ (Female)

Soá CMND/HC (ID/Passport No.): .......................................................... Ngaøy caáp (Date of issue): .......................................... Nôi caáp (Place of issue): ..........................................

Quoác tòch (Nationality): Vieät Nam (Vietnam) Hoa Kyø (US) Khaùc (Other): ...................................................... Khoâng quoác tòch (Non-Nationality.)

Soá thò thöïc (chæ daønh cho tröôøng hôïp khoâng Quoác tòch) (Visa No., only applied for non-nationality customer): ..........................................................................................................................

Caáp bôûi (Issued by): ............................................................................................................................................................................................................................................

Tình traïng cö truù taïi Vieät Nam (Residence status in Vietnam): Ngöôøi cö truù (Resident) Ngöôøi khoâng cö truù (Non-resident)

Ñòa chæ thöôøng truù (Permanent address): .....................................................................................................................................................................................................................

Ñòa chæ lieân laïc (Current Address): ........................................................................................................................................................................................................................

Điện thoại nhà (Home phone No.): ...................................................................................... Điện thoại di động (Mobile No.): .....................................................................................

Ñòa chæ Email (Email address): ..............................................................................................................................................................................................................................

Ngheà nghieäp (Occupation): ..................................................................................................................................................................................................................................

Chöùc vuï (Position): ..............................................................................................................................................................................................................................................

THOÂNG TIN CUÛA KHAÙCH HAØNG TAÏI HOA KYØ (QUYÙ KHAÙCH VUI LOØNG ÑIEÀN CAÙC THOÂNG TIN SAU NEÁU COÙ. TRÖÔØNG HÔÏP ÑEÅ TROÁNG, XEM NHÖ QUYÙ
KHAÙCH KHOÂNG COÙ CAÙC THOÂNG TIN NAØY VAØ NGAÂN HAØNG KHOÂNG COÙ TRAÙCH NHIEÄM VEÀ VIEÄC THU THAÄP CAÙC THOÂNG TIN LIEÂN QUAN COÙ THEÅ PHAÙT SINH)
CUSTOMER’S INFORMATION IN US (PLEASE FILL IN THE FOLLOWING INFORMATION IF AVAILABLE. IN CASE OF BLANK, WHICH MEANS YOU DO NOT HAVE THIS INFORMATION,
THE BANK SHALL BEAR NO RESPONSIBLE FOR THE COLLECTION OF RELEVANT INFORMATION THAT MAY ARISE)

Ñòa chæ thöôøng truù (Permanent address): .....................................................................................................................................................................................................................

Ñieän thoaïi (Phone No.): .......................................................................................................................................................................................................................................

Ñòa chæ lieân laïc (Current Address): ........................................................................................................................................................................................................................

Ñòa chæ hoøm thö taïi Hoa Kyø (P.O. Box in US): Khoâng (No) Coù (Yes): ........................................................................................................................................................

Taøi khoaûn ôû Hoa Kyø (Account in US): Khoâng (No) Coù (Yes): ........................................................................................................................................................

Hôïp ñoàng uûy quyeàn ñaïi dieän taïi Hoa Kyø (The power of attorney in US): Khoâng (No) Coù (Yes): ...................................................................................................................

Tröôøng hôïp Quyù Khaùch coù quoác tòch Hoa Kyø hoaëc nôi sinh taïi Hoa Kyø hoaëc coù moät trong caùc thoâng tin treân, ñeà nghò Quyù khaùch ñieàn ñaày ñuû thoâng tin vaøo caùc bieåu maãu
do Sacombank cung caáp theo quy ñònh cuûa Cô quan Thueá vuï Myõ.
(According to the IRS regulations, please contact to our staff to receive the appropriate form(s), then complete and return to us, if (1) you were born in US; or (2) you are U.S. citizen (including dual
citizen) or U.S. resident alien for tax purposes; or (3) you have one of the US information as above).

THOÂNG TIN KHAÙC CUÛA KHAÙCH HAØNG (ADDITIONAL INFORMATION)

Quyù khaùch vui loøng cung caáp caùc thoâng tin trong muïc naøy ñeå Sacombank thöïc hieän caùc chöông trình chaêm soùc khaùch haøng.
(Please fill in all these fields for Sacombank Customer Care Service purpose)

Teân cô quan (Company name): ............................................................................................................................................................................................................................

Ñòa chæ cô quan (Office Address): .........................................................................................................................................................................................................................

Tình traïng hoân nhaân (Marital status): Ñoäc thaân (Single) Ñaõ laäp gia ñình (Married)

BM-TTKH.QLTTKH.01-02 (......../......./...............)
 THOÂNG TIN NGÖÔØI ÑAÏI DIEÄN/NGÖÔØI GIAÙM HOÄ (LEGAL REPRESENTATIVE’S INFORMATION)

Hoï vaø teân (Full name): .........................................................................................................................................................................................................................................

Soá CMND/HC (ID/Passport No.): .......................................................... Maõ KH (Customer code): ............................................ Moái quan heä (Relationship): .....................................

Soá ñieän thoaïi di ñoäng (Mobile No.): ..................................................... Ñòa chæ email (Email address): ...................................................................................................................

Toâi cam keát nhöõng thoâng tin treân laø ñaày ñuû, chính xaùc, ñuùng söï thaät vaø phuø hôïp vôùi caùc quy ñònh phaùp luaät.
Toâi hoaøn toaøn chòu traùch nhieäm tröôùc phaùp luaät, vôùi Beân thöù ba vaø mieãn tröø traùch nhieäm cuûa Sacombank baát kyø tranh chaáp naøo phaùt sinh hoaëc lieân quan ñeán tính xaùc
thöïc cuûa caùc thoâng tin maø Toâi cung caáp.
Toâi ñeà nghò Sacombank söû duïng thoâng tin treân cho taát caû caùc giao dòch cuûa Toâi taïi Sacombank.
Toâi ñoàng yù raèng, caùc thoâng tin trong phieáu ñaêng kyù thoâng tin naøy cuøng vôùi Giaáy ñeà nghò môû taøi khoaûn ngaøy ...../...../........... vaø caùc quy ñònh khaùc cuûa Sacombank seõ taïo
thaønh thoûa thuaän raøng buoäc traùch nhieäm giöõa Toâi vaø Sacombank.
I hereby certify all the above information is full, precise, true and in consistent with the related provisions of laws.
I shall bear full responsibility before the law, the third party and disclaim all of liability of Sacombank in any dispute arising or relating to the authenticity of the information that I provided.
I hereby authorize and permit Sacombank to use the above information for all of my transactions at Sacombank.
I agree that the information in this customer information form and the Request for opening of account dated ...../...../........... and other provisions of Sacombank shall constitute a binding agreement between
Sacombank and me.

Chöõ kyù laàn thöù nhaát (Signature) Chöõ kyù laàn thöù hai (Signature confirmation)
(Kyù vaø ghi roõ hoï teân/Signature and full name) (Kyù vaø ghi roõ hoï teân/Signature and full name)

PHAÀN DAØNH CHO SACOMBANK (FOR SACOMBANK USE ONLY)

Ngaøy/Date ........... thaùng/month ......... naêm/year ..................

Nhaân vieân thöïc hieän (Kyù vaø ghi roõ hoï teân) Tröôûng ñôn vò (Kyù vaø ghi roõ hoï teân)
Received and checked by (Signature and full name) Approved by (Signature and full name)

Taát caû thoâng tin Quyù khaùch cung caáp seõ ñöôïc Ngaân haøng löu tröõ vaø baûo maät. All your information gathered in this form will be kept strictly confidential.
BM-TTKH.QLTTKH.01-02 (........./........./..............)

Tröôøng hôïp Quyù khaùch haøng thaéc maéc caùc quy ñònh veà ”Chuû sôû höõu höôûng lôïi”, “Thoâng tin cuûa Khaùch haøng taïi Hoa Kyø” thì Quyù khaùch haøng vui loøng tìm hieåu caùc thoâng
tin naøy vaø caùc thoâng tin coù lieân quan treân website: www.sacombank.com.vn hoaëc lieân heä tröïc tieáp vôùi nhaân vieân tö vaán cuûa Sacombank ñeå hieåu roõ caùc noäi dung neâu treân
nhaèm baûo ñaûm quyeàn lôïi cho Quyù Khaùch haøng.
Neáu coù söï maâu thuaãn giöõa ngoân ngöõ Tieáng Vieät vaø Tieáng Anh thì ngoân ngöõ Tieáng Vieät ñöôïc öu tieân aùp duïng.
If having any questions related to the provisions of the "Beneficial Owner", "Customer information in US", please kindly look for these information and other relevant information on website: www.sacombank.com.vn
or make direct contact to the Sacombank’s staff to understand the content as mentioned above to ensure Customer’s rights.
If there is any conflict between the Vietnamese version and English version, the Vietnamese version shall prevail.