For office use

Lloyds TSB Bank plc, ATT, New Tower (5F), 2-11-7 Akasaka, Minato-Ku, Tokyo 107-0052.

Applicant ID: 120967

www.golloyds.com

GOLLOYDS OVERSEAS REMITTANCE ACCOUNT APPLICATION Go

Family Name First Name Middle Name Date of Birth Nationality Occupation

Mendoza

Gabriel

Evora

1979/07/20

PHILIPPINES

Business Development Analyst

) )

Home Address

Must be current and match Alien Registration Card/Drivers License

Tel Fax Mobile E-mail

( (

Unit 105, Leo Palace 21, 4-12-22 Goshikiyama, Tarumi-ku Kobe-shi Hyogo-ken,655-0035
Company Name and Address

080-5076-1979 koponov@yahoo.com

WeServ Systems Ltd. 3/F Manulife Place 4-20-1 Kamata Ota-ku Tokyo-to,144-0052
Fax ( )

Tel Fax

( (

03

) )

5480

8507

Advice of Transfer to be received by

x Mail - Home

Please check (only one) the bank you wish to use to make the domestic transfer (Furikomi) to us (typically the bank at which you hold your Yen account). TSB Sumitomo Mitsui Other To open a GoLloyds account foreign residents are required to provide photocopies of two of the following:

How did you learn about this service? Go Which paper Which magazine Which website Search engine Google Other Introduced by Keyword

x Mizuho

Tokyo Mitsubishi

Signature or seal /
M D Y

Go

Current Alien Registration Card (both sides) Japanese Drivers Licence Passport (photo page)

Please remember to include copies of 2 pieces of ID

a) I hereby confirm that the terms and conditions attached will govern all remittances I undertake through Lloyds TSB Bank using my GoLloyds Overseas Remittance Account. b) I declare all information given is correct. If the purpose of an individual remittance is different from that stated, I shall make a supplementary purpose declaration to The Bank at the time of remittance.

a) TSBGo b)

Items marked with a square must be completed

Source of income/wealth Expected number of transfers per year Expected total remittance amount per year (Yen)

Salary

9-12

1-2 million

1.

Beneficiary Name

Christine Mendoza

Beneficiary Bank and Branch Address

Beneficiary's current country of residence (if other than yourself)

Beneficiary's relationship to yourself (if other than yourself)

Philippine National Bank Makati Poblacion Branch, Angono cor. Cardona St., JP Rizal, Makati

PHILIPPINES

Spouse

Purpose of Remittance

Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.)

Remittance
Please be specific. e.g. if purchasing goods, please indicate what kind of goods

Account number

Currency of Transfer

Special Instructions

PNBMPHMM

27530300019

US Dollar
Yen

If you wish to add more beneficiaries, please use the space provided on the next page.

2.

Beneficiary Name

Beneficiary Bank and Branch Address

Beneficiary's current country of residence (if other than yourself)

Beneficiary's relationship to yourself (if other than yourself)

Purpose of Remittance Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.) Please be specific. e.g. if purchasing goods, please indicate what kind of goods Account number Currency of Transfer Yen Special Instructions

3.

Beneficiary Name

Beneficiary Bank and Branch Address

Beneficiary's current country of residence (if other than yourself)

Beneficiary's relationship to yourself (if other than yourself)

Purpose of Remittance Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.) Please be specific. e.g. if purchasing goods, please indicate what kind of goods Account number Currency of Transfer Yen Special Instructions

4.

Beneficiary Name

Beneficiary Bank and Branch Address

Beneficiary's current country of residence (if other than yourself)

Beneficiary's relationship to yourself (if other than yourself)

Purpose of Remittance Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.) Please be specific. e.g. if purchasing goods, please indicate what kind of goods Account number Currency of Transfer Yen Special Instructions