Form Daftar Dan Tambah Token

8/12/2019 Form Daftar Dan Tambah Token

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Application for Service and Token Registration

cash@work

Please fill using block letters and please tick whichever is applicable and please give cross for un-filledsection.

The undersigned,

1. NameTitle

ID Number (Passport or National ID)

Address

Phone No.

Cellphone No.

2. NameTitle

ID Number (Passport or National ID)

Address

Phone No.

Cellphone No.

each acting in his capacity as stated above, therefore validly act for and on behalf of (hereinafter

referred to as CUSTOMER), hereby apply for Service and Token cash@work Registration, provided by PT

Bank Danamon Indonesia, Tbk. (hereinafter referred to as BANK), with following data :

COMPANY PROFILE

Companys Name :

Domicile and Office Address :

City :

Postal Code :

Phone Number :

Fax Number :

E-mail Address :

Contact Person :

(Filled by Bank)

CIF:

Corporate ID:

Servicing Branch Code:

LOB:

RO/RM Code


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Industry Segmentation :

Banking Financial Institutions Utility and Infrastructure Electronic

Non Banking Financial Institutions Agriculture and Mining Trading

Consumer Goods Industry Automotive Chemical Industry

Property and Construction Textile and Garment Others______

SERVICE PACKAGE

Inquiry Basic Premium

REGISTERED ACCOUNT

No Account Number/

Credit Line

Under the Name of Types of Deposits/Credit Types of Access

Savings Giro Deposit Loan Debit Credit Inquiry

1.

2.

3.

4.

etc.

Notes :

1) Please attach related documents;2) Please fill according to the type of savings;3) Only available for inquiry.

TOKEN

No User ID User Name Token Serial No.* A B C D

1. . .

2. . .

3. . .

4. . .

Notes :

* : filled by Bank for the order of new token

A : Order of new token B : Replacement for lost/broken card

C : Changing User ID D : Block/Unblock


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COSTS

Cost of Service package/monthly

Cost of Token

Bank account number that will be debited for monthly fee :

STATEMENT AND POWER OF ATTORNEY

By signing this form, CUSTOMER stated the followings :

1. TOKEN RECIPIENT assigned by CUSTOMER are :a. Name :

Title :

ID Number (Passport or National ID) :

Address :

Phone No. :

Cellphone No. :

b. Name :Title :

ID Number (Passport or National ID) :

Address :

Phone No. :

Cellphone No. :

2. Authorized the registered user of User ID to execute Financial and Non-Financial Transaction withcash@work Service.

3. All information and data stated in this form are true, complete and valid as well as basis for CUSTOMERsparticipation in cash@work Service.

4. Unless stated differently in this form, terms used in this form have the same meaning and definitions asstated in General Terms and Conditions of cash@work Service.

5. CUSTOMER has read and agree to abide by the General Terms and Conditions of cash@work Servicementioned behind this form as an integral and inseparable part.

[Place, Date/Month/Year]

CUSTOMER TOKEN RECIPIENT

stamp duty

(signature and name) (signature and name) (signature and name) (signature and name)


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Verification and Application (filled by Bank)

Account and Signature Verified (by Branch)

Account Checked

Name & Signature Date

Signature Verified


Application Approved by Official


Corporate ID and Account Registered (by CMDImplementation)

Processed


Checked


Approved


Parameter Application (filled by Bank)

Inputted and processed by Parameter Div./Common File

Name & Signature Date Name & Signature Date

PROOF OF RECEIPT

TOKEN RECIPIENT hereby stated :

1. Have received materials/instruments in forms of User ID and Token stated in Service and Tokencas@work application form;

2. Have received the above mentioned instruments in good and complete condition;3. Have full responsibilities on the execution and the use of the above mentioned instruments.

RECIPIENT

(TOKEN RECIPIENT)

(signature and name) (signature and name)

THE SURRENDER

(BANK)

(signature and name) (signature and name)

Form Daftar Dan Tambah Token

Documents

Transcript of Form Daftar Dan Tambah Token