Transcription of Remittance Application Form - Philippine National …
1 A Remittance Subsidiary of the Philippine National Bank Remittance Application form Remitter s Information Complete Name: Date: Complete Address: Postal Code: Tel. No/s: E-mail Address Birth Date (mm/dd/yy) Identification Driver s License Passport Citizenship Permanent Card Others_____ ID No: Expiry Date (mm/dd/yy) Issuing Authority: Occupation: Employer Name/Address: : Recipient s Information Check box if recipient is same as the remitter. If different, pls. indicate details below.
2 Complete Name: Relationship to Sender: Complete Address: Tel. No/s: Mobile No: Remittance Instruction (check one that applies) Credit to PNB Account or GFMC (indicate acct. no or GFMC no. here) Availment of GFMC Door to Door Pick-up Credit to Other Bank (indicate bank details below) Bank Name Account Number Branch Name Acct Currency (Php/US) Consent is given to PNB Global Remit to disclose this information to Law Enforcement Authorities, if required. I also hereby certify that the foregoing information is true and accurate to the best of my knowledge.
3 Received by: _____ Printed Name and Signature of PNB Representative _____ Signature over Printed Name and Date (mm/dd/yy)
