MKD_30
072019_V-22

Given name

Given name
/Continue to next page (1 of 2)
Form: 50-153
VATNo.: L001-100047149

Account type

Account name
/Currency type
/KHR
/USD
/THB
/Other

/Future kid account
/ESA
/IRA
/Savings account
/HSA
/Current account /Demand deposit

Mobile phone No.
/Credit card account
/Passbook /Yes /No)
/Other
d d m m y y
ធរ េអសលី ភីអិលស
ACLEDA Bank Plc.
Personal Account Opening Application Form

 
Please fill in this application properly.
/Title

Name in Khmer

Name in Latin
Name in Khmer Name in Latin

Date of birth

Place of birth
/Ms./Mrs./Mr.
/Dual citizen /No /Yes
/No /Yes /Person(s)

Nationality

Profession

Surname

Surname
/Applicant’s information

Type of legal ID
/Family book/Passport/National ID
Politically exposed persons (PEPs)-Domestic Politically exposed persons (PEPs)-Foreign
Money changers
Money Remittance Companies (incl. of their agents) Other Cash-intensive customers
/Other

/Number /Expiry date/Issued date
dd mm yy
/ /
dd mm yy
/ /
Real estate businesses (incl. agents)

Contact address
/Mobile phone number /E-mail
/Building name or No. /Street name or No. /Group No. /Village

/Commune /District/City /Province/Capital
Dealers in precious metals and stones Casino /Other:
/Joint account
/Joint account's information

ACLEDA Unity ToanChet Registration
/Title

Given name

Given name
d d m m y y

Name in Khmer

Name in Latin

Date of birth

Place of birth
/Ms./Mrs./Mr.
/Dual citizen /No /Yes

Nationality

Profession

Surname

Surname

Type of legal ID
/Family book/Passport
/National ID
Politically exposed persons (PEPs)-Domestic Politically exposed persons (PEPs)-Foreign
Money Remittance Companies (incl. of their agents) Other Cash-intensive customers
/Other

/Number 
/Expiry date
/Issued date
Money changers
Real estate businesses (incl. agents)
Dealers in precious metals and stones Casino /Other:

Contact address
/Telephone number /E-mail
/Building name or No. /Street name or No. /Group No. 
/Village

/Commune 
/District/City /Province/Capital
dd mm yy
/ /
dd mm yy
/ /
Form: 50-153
Page 2 of 2
Enrolled Biometric
Remark:
Name:
Signature:
Name:
Signature:
Enrolled by
Dual controlled by
Name:
Signature:
Prepared by
Verified by
Customer's photo number:
 / FOR BANK USE ONLY
Name:
Signature:
Referred by (ID):
Opening Date:
Oicer ID:
Category No.:
Customer ID:
Customer Type:
Shareholder/Board Member Others
Account number
ACLEDA Sta
d d m m y y
Customer's photo number: I M
I M
I M
Customer ID:
Spouse Relative Friend Other:
Customer's photo number:
Joint
account
holder
Spouse Relative Friend Other:
Customer ID:

I/we authorized the bank to disclose my/our account information to the relevant authorities.


I/we authorized the bank to disclose my/our information having with ACLEDA Bank Plc. to its subsidiaries and partners for oering new services.
/Date

/Applicant’s and/or joint account holder’s signature or thumb print
1-
2-
3-
4-
6-
7-
8-
9-
5-
/Savings for safety
/Savings for interest
/Savings for dream house
/Savings for buying personal appliance
/Business operation or goods/service payment
/Loan disbursement and repayment
/Receiving money either local or oversea transfer
/Children education
/Savings for travelling
/Retirement-private institute
11-
12-
13-
14-
15-
16-
 ()/Purpose of using account (Only one selection)
/Yes /No
10-
/Bank confirmation
/E-banking services
/Bidding project and trade finance
/Security trading
/Tari/ patent/ business license
/Other17-
/Insurance
dd mm yy
/ /
/Title

Given name

Given name
d d m m y y

Name in Khmer

Name in Latin

Date of birth

Place of birth
/Ms./Mrs./Mr.
/Dual citizen /No /Yes

Nationality

Profession

Surname

Surname

Type of legal ID
/Family book/Passport/National ID
Politically exposed persons (PEPs)-Domestic
Politically exposed persons (PEPs)-Foreign
Money Remittance Companies (incl. of their agents) Other Cash-intensive customers
/Other

/Number /Expiry date/Issued date
Money changers
Real estate businesses (incl. agents)
Dealers in precious metals and stones Casino /Other:

Contact address
/Telephone number /E-mail
/Building name or No. /Street name or No. /Group No. /Village

/Commune 
/District/City /Province/Capital
dd mm yy
/ /
dd mm yy
/ /
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