This document contains fields for collecting a customer's personal information such as full name, date of birth, ID/passport number, occupation, address, nationality, gender, and contact details. It also includes fields for representative's information if applicable, registration for debit card and banking services, customer declaration, and terms and conditions for using the bank account.

1. Fullname
Ngay sinh:
Date of birth
Nghe nghiep:
Occupations
The CCCD/CMND/HQ chieu/So th] thirc:
ID/PassportNo/Visa
Tlnh trang elf tru tal Vi~t Nam:
Residence status in Vietnam ~
Dia chi lien 1(,lC: ""'0 10
Contact address
Dia chi thuong tru:
Permanent address
1'-/((U 'j .
OGlull A9f5
I
sinh: lttPl( ('[Cru'jE--rv
of birth
Chuc vu:
Title r
~Cn~(L(317 Ngay cap: 2if(bJ.--P-utl NO'icap: tt- frtA-(
_j Date of issue Placeof issue
bLINgLfai CLftru D NgLfai khong CLftru
Gender
Quoc tich:
Nationality
Male Female
ng t ng t~i Hoa Ky
Customer's information in US
Tnrong hop C6, Quy khach vui long dien
Pleasefill in the followina information in case
Dja chi lien lac:
Contact address
Dla chi thuong tru:
Permanent address
Di~n thO(,li:
Phone
rai kho':m t(,li Hoa Ky:
No Yes
Di~n thoai:
Phone
Resident
Cr TtlUfJK~ '[1itf'{H
I1t--
ng: (Jj36 j]l be j
phone
Non - resident
La fV(r BillY lt~"'NO"
Email:
THONG TIN NGU'01 £>1:1
DI~N THEO PHAp LU~T (NEU CO) /REPRESENTATIVE'S
INFOMATION (IF ANY)
DCha/me (Father/Mother) I
DTheo chi djnh cua Toa an (Accordingto court)
HQva ten: J
Fullname
Ngav sinh: N 'Iisinh:
Date of birth Plate of birth
Nghe nghiep:
Occupations
The CCCD/CMND/HQ chieu/So th] thirc:
ID/PassportNo/Visa
Tlnh trang elf tru tal Vi~t Nam:
Residence status in Vietnam
Dja chi lien lac:
Contact address
Dja chi thtrong tru:
Permanent address
Di~n thoai:
D Giarn hQ (Guardian)
D Khac (Others)
Gi&i tinh D Nam D Nfr
Gender Male
Quoc tich:
Nationality
Female
Chirc vu:
Title
Ngay cap:
Date of issue
D NgLfai CLftru
Resident
NO'iCap:
Placeof issue
D NgLfai khong elf tru
Non - resident
Email:
Dia c I hom thLf t(,li Hoa Ky
P.O in US
D Khong D C6:
No Yes
D Khong D C6:
No Yes
D Khong D C6:
No Yes
Ky ho~c nO'i sinh t(,li Hoa Ky ho~c c6 mot trong cac thong tin tren, de
cac bieu m§u do NCB cung cap thea quy dinh cua CO'quan Thue Vl,l
HQ'pdong uy quyen d(,li dien t(,li Hoa Ky:
Thepower of attorney in US
TrLfang hQ'p Quy khach c6 quoc tich
nghi Quy khach dien day du thong tin
My.
According to the IRSregulations, please contact our staff to receive the appropriate forms, then complete and return to us, if (1) you
were born in US;or (2) you are US citizen flnI-IIJrHnn dual citizen) or US resident alien for tax purposes; or (3) you have one of the US
information as above.
DE NGH! SLr Dl,JNGD!CH Vl,J/REGISTRATIONINFORMATION

2. toai tien
Typeof currency
dTai khoan thanh toan
Currentaccount
~
inen glii tiet kiern
Savingdeposit
VNO 0 USO
o Tal khoan tien glii co ky han
Fixeddeposit
o Khac
Other
o Khac
Other
toai hlnh
Type
VEU CAU PHAT HANH THE GHI N(!/DEBITCARD
I 1. Thong tin the chinh (Primarycard holder's information)
l... _ ·····················r=:lr=il==i"F=r···'F
Ten chu the chfnh in noi tren the (Chfr in, toi da 20 ky tu) ""-',_u._.,__".........
, '---',~"~~~ L........J'-~,__J'-'-'
'---'~-" .....
-''---' ~L_JL_-'L........J
PrimaryCardHolder/name embossed (Maximum 20 characters, in capital letter) /
Hang the [J Chudn 0 Vang Lo~i hlnh phat hanh Qi'ThLlang
Class Standard Gold Issuance type Regular
o Dang ky dich vu thanh toan true tuyen
...................
fi.~9J~.~~r.£~gt!.!.[!!.~!:.~.~
~.~[.'!./~~ _._ . _
...
I 2. Thong tin the ph", (Supplementary card holder's information)
'·H"Qv~t~n ..
ch~-tii~
ph~···i:" _ _ __ _-_ _- __
··
..GTGr"ifnh··············cI"Niim..·
Fullname 1 Gender Male
NO'iCap:
Placeof issue
Email:
oNhanh
Quick
o Nfr
Female
The CCCO/CMNO/Ho chieu:
ID/PassportNo
Ngay sinh:
Date of birth
o Dang ky dich vu thanh toan true tuyen
Register Ecommerce service
HQ va ten chu the ph", 2:
Fullname 2
The CCCO/CMNO/Ho chieu:
ID/PassportNo
Ngay sinh:
Date of birth
o Dang ky dich vu thanh toan true tuyen
Ecommerce service
Ngay Cap:
Date of issue
Oi dong:
Mobile phone
Ngay Cap:
Date of issue
Oi dong:
Mobile phone
Gi&i tfnh
Gender
NO'iCap:
Placeof issue
Email:
o Nam
Male
o Nfr
Female
(*) Do baa gam d;ch VI,! thOngboo
bien Gongso dU'/ Notification of
account balance.
Packservice
Hlnh thtrc xac thuc:
Verifyby
G(SMS (vui long dang ky dich VI,! SMS Banking/Please register SMS Bankingservice)
Basic
o Cao Cap
Advance
SMS Banking*
Oi dong 1: £133'33~H)
(Mobile No.1)
Oi dong 2:
(Mobile No.1)
Ten truy cap:
Username
Goi dich vu:
o Email:
(Chiap dl,!ngcho Internet banking/Used onlyfor Internet bonking Service)
HO SO'£)INH KEM/ENCLOSED DOCUMENTS
Ban sao cae glay toosau co xae nh~n sao y cua CO' quan co tham quyen
Copiesof each of the following documents certified by authorized organization
JGiay tatuy than (CCCO/CMNO/Ho chieu/Visa) 0 Giay khai sinh
ID/Passport/VisaNo Certificatebirth
o Xac nh~n/Quyet dinh cua ngLlai giam hO 0 Cac giay ta khac
Appointing of guardian Other documents
o Quyet dinh chi dinh ngLlai d~i dien thea phap lu~t
Appointing of representative
CAM KET CUA KHAcH HANG/CUSTOMER'S DECLARATION
1. NhLlng thong tm tren day la dung Sl/ th~t va hoan toan ch!u trach nhlem ve cac thong tm da cung cap.
The information provided above is true and full responsibilityfor above information.
2. Tai/Chung tai xac nh~n da doc, hieu r5 va cam ket thl/c hien dung cac quy dinh, dieu khoan, dieu kien ma va sli
dl,lng tai khoan, the ghi nq, dieh Vl,l ngan hang dien tli t~i Ngan hang TMCP Quae dan dLlqe dfnh kem v&i Giay de
nghi nay va quy dinh phap lu~t hien hanh cua Viet Nam.
t/We confirms to have read, understood and hereby commits to comply with the regulations,terms and conditions stipulated enclosed this
application by National CitizenBank and the existing law of Viet Nam on the opening, using of account, debit card and ebanking service.
2

3. NgU'Cri lien quan (Ky va ghi ra h
Other party (Sign and [ullnome]
.Ngav thang narn
Date month year
Khach hang ( Ky va ghi ra ho ten)
Client (Sign and [ullnome}
M~u chCi'ky 1
Specimen signature 1 2
M~u chCi'ky 1
Specimen signature 1
M~u chCi'ky 2
Specimen signature 2
Specimen
Account No
o VND
o USD
Giao dlch vien
Tel/er
TrU'cYngdO'n vi I
NgU'CridU'Q'cuy quyen
Director/Authorized signature
o Khac
Other
56 the chfnh DDDDDODDL_JL_JL_.IJL_J DODDDODD
Primary card No
So the phu I DDDDDDDD DDDDDDDD
:;;~e;7;~t~l~
cmUD DODD DODDDDDD
Supplementary card No 2
£lIEUKI~N,£lIEUKHOANMC1vA suDl)NG TAl KHOANT~I NGAN HANGTMCPouoc DAN
(Dieu ki~n, (lieu khoan nay dirac dinh kem voi Gioy de ngh; kiem noo dong sti' dt,mgd;ch VI) dant: cho cci nhOn)
£lieu 1. Caetlt ngil Slt dung trong ban dieu ki~n, dieu khoan
nay dU'Q'e
hieu nhtr sau:
a. Nganhimg{NH): la Ngan hang TMCPQuoe Dan (NCB)
b. Chu tai khoan - Khach hang (KH): la ca nmanma tai khoan
t<;liNCB.
e. rai khoan (TK):la TKcua eanhan.
d. Dong TK: la vi~c NH dong he SC1 TK,so TKIdabi dong co the
dU'qcSlrdvng de dang ky cho KHkhac
e. T<;Im
khoa TK: la vi~c NH t<;lmdltng moi giao djch tren mot
phan hay toan bOso dU'tren TK. I
f. Phong toa TK: la vi~c NH ti;lm dltng moi giao djeh chuyen
khoan, chi tien tren mot phan hay toan b~ so dU'tren TK.
g. ChLrngtlr TK: bao gem giay bao NO',bao Co, sao ke, giay
bao so dU'TK. I
h. 56 dU't6i thieu: la 56tien toi thieu chu Tr phai duy trl tren
TKti;li mQithai diem.
i. 56 dU'dU'qcphep Slr dl,Jng:la 56 tien KHFO the Slr dl,Jngde
chi tieu va thanh toan tlt TKcua mlnh. s~dU'dU'qc phep Slr
dl,Jngbang so dU'co tren TKtrlt di CC3c khioanphong toa trlr
56 dU't6i thieu va cong v6'i hc;lnmLrcthalchi chU'aSlrdl,Jng
(neu co).
£lieu 2. Quyen va nghia vI,!euacaeehu tai k oan
1. chi} tai khoan thanh tocin coeciequyen sau:
a. Slr dung 56 tien tren tai khoan thanh toan eua mlnh de
thl,J'e
'hi~n cae I~nh thanh toan hO'pphap, hqp I~. Chu tai
khoan thanh toan dU'qc Ngan hang ti;lo dieu ki~n de Slr
dung tal khoan thanh toan cua rnlnh thuan tien va an
toan:
b. LIla chon Slr dung cac phirong ti~n thanh toan, dich Vl,J
va
tien fchthanh toan do Ngan hang cung Lrng;
c. Vi~c Slr dl,JngTK phai,tuan thu cac quy dinh eua phap lu~t
va quy ehe eua NH. Uy quyen cho ngU'O'i
khae Slr dvng tai
khoan thanh toan thea quy dinh eua phap lu~t;
d. Yeu eau Ngan hang thl/c hi~n cae I~nh thanh toan hqp
phap, hqp I~ va dU'O'c
cung cap thong tin ve cac giao djch
thanh toan, so dU' tren tai kho{m thanh toan cua mlnh
thea thea thu~n v6'i Ngan hang;
e. DU'O'cyeu cau Ngan hang nC1ima tai khoan ti;lm khoa,
dong tai khoan thanh toan khi can thiet; dU'qc glri thong
bao cho Ngan hang ve vi~c phat sinh tranh chap ve tai
khoan thanh toan chung giO'acae ehu tai khoan thanh
toan chung;
f. Cac quyen khac thea quy dinh eua phap lu~t ho~c thea
thea thu~n trU'6'c bang van bfm giCi'aehu tai khoan v6'i
Ngan hang khong trai v6'i quy dinh cua phap lu~t hi~n
hanh.
2. chi} tai khoan thanh tocin coecienghia VI! sau:
a. Dam bao co du tien tren tai khoan thanh toan de thl,J'e
hi~n cac I~nh thanh toan da I~p. TrU'O'nghqp co thea
thu~n thau chi v6'i Ngan hang nai ma tai khoan thl phai
thl/c hi~n eac nghia Vl,Jlien quan khi chi tra vU'qt qua 56
dU'Cotren tai khoan;
b. Chaphanh cac quy dinh ve mava Slrdl,Jngtai khoan thanh
toan ti;li Quy dinh nay;
c. Kip thai thon~ bao eho Ngan hang nC1ima tai khoan khi
phat hi~n thay co sai sot, nham I~n tren tai khoan eua
mlnh ho~c nghi nga tai khoan eua mlnh bj Iqi dl,Jng;
3