1. No category

PERSONAL CUSTOMER DATA FORM
New Customer
Data Updating
Beneficial Owner
To be filled by the Bank
Branch Code :
Customer Class
:
Branch Name
:
Business Scale
:
Date
:
In the event of Joint Account Customer
:
No. GCIF
:
GCIF No. of Other Account Holder
:
Please answer all questions completely and correctly using capital letters and in case of multiple choices
please check (v) the appropriate box.
PERSONAL DATA
Full Name
(as shown in the ID)
Type of ID
ID Card
Driving License
Passport
KIMS/KITAS
Others _______________ No.
Valid Until
-
-
-
-
ID number
Status of Place of Residence
Occupied since
Other ID
Valid Until
Place of Birth
-
Date of Birth
Home Phone No.
-
-
-
Mobile Phone No.
Religion
Islam
Christian
Gender
Male
Female
Marital Status
Married
Single
Catholics
Buddha
Hindu
Divorced/Widowed
Others ____________________
Number of Dependent(s)
Name of Spouse/Parent
Date of Birth
-
-
(To be filled if the occupation of the Customer is homemaker (Name & date of birth of the Husband), or Student (name & date of birth of Parent)
Nationality
Indonesia
Others _______________________________ Citizenship
Education
Senior High School
Academy/Diploma
Bachelor's Degree
Resident
Master's Degree
Non-Resident
PHD
Others ____________________________
Tax Registration No.
Mother's maiden name
Name of the other account holder
(If Joint Account Customer)
ADDRESS DATA
Address as shown in the ID
RT
RW
Kelurahan
Sub-District
District/Regency
Province
P.O Box
Phone No & Fax No
Address of Place of Legal Domicile
RT
(to be filled only when differ from the address on the ID)
RW
Kelurahan
Sub-District
Province
District/Regency
P.O Box
FINANCIAL DATA
Main Income
(Annual gross, in Rupiah)
Source of Main Income
Salary
Busines
Personal Saving
Commission
Invesment Selling
Investment
Additional Income
Others ______________________
(Annual gross, in Rupiah)
Source of Additional Income
Salary
Intended use of funds
Business
Busines
Personal Saving
Personel Saving
Commission
Commission
Invesment Selling
Investment
Monthly Cash Inflow
Investment
Others ______________________
Others _______________________________
(in Rupiah)
Monthly Cash Outflow
(in Rupiah)
Monthly Cash Inflow Frequency
0-10 times
11-20 times
21-30 times
Others _____________________________
Monthly Cash Outflow Frequency
0-10 times
11-20 times
21-30 times
Others _____________________________
EMPLOYMENT DATA
Profession
Civil State Employee / Private Sector
Type of Work
Professional
Entrepreneur
Student
Retiree
Type of Company
Homemaker
PT
Business Industry
Fax No.
Position
Others__________________________________
CV
Cooperative
Others _____________
Start of Work
-
-
Name of Company
Office Phone No.
-
Email Address :
Office Address
RT
Kelurahan
Sub-District
Province
District/Regency
RW
P.O Box
I/We the undersigned hereby state that all information provided by me/us on this application is true and accurate as well as updated.
In the event the document/information I/we provided on this application is incorrect/false, therefore the Bank shall be entitled to close my/our account. All risks incurred due to
error in data provision by me/us are the responsibility of me/us
CUSTOMER'S APPROVAL COLUMN
,
Account Holder,
I/We (select one)
Shall be willing to accept Bank products and/or services offerings
through personal communication facility
Shall be willing to accept Bank products and/or services offerings
through personal communication facility AND to give approval to
the Bank to use/give personal data and/or information to third
parties for the interest of the Bank including
Shall not be willing to accept the abovementioned.
Signature
(
Signature & Full Name
Full Name )