www.bracbank.

com

Account Related Customer Declaration Form

(This is not a payment instruction)

Date: D D M M Y Y Y Y Mobile Number:

Branch Manager
BRAC Bank Ltd.
Branch:

Account Number:

Account Title:

Dear Sir/Madam,

Accountholder’s Signature 2nd Accountholder’s Signature

(if joint)

FOR BANK USE ONLY

 Signature(s) Verified Customer ID:

 Customer is physically present

Received By Action Taken By