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:
Oicer 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 oering 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
/ /
