Personal Account Opening Application Form · Name in Khmer េ ះ អក រ ំង Name in Latin...

MKD_30072019_V-22

�មខ��ន:Given name


តេ�ទំព័រេ��យ/Continue to next page (1 of 2) Form: 50-153VATNo.: L001-100047149

�បេភទគណនីAccount type

េ��ះគណនីAccount name

�បេភទរូបិយប័ណ�/Currency type

��ក់េរៀល/KHR

��ក់ដុ��រ/USD

��ក់�ត/THB

េផ�ងៗ/Other:

គណនីអ�គតកុ�រ/Future kid account

មូលនិធិសិក�អប់រ�/ESA

មូលនិធិេ�ធននិវត�ន/៍IRAបេ��ើសំៃច/Savings account

មូលនិធិ�ំ�រសុខ�ព/HSA

ចរន�/Current account សន�ំ�មត�មូវ�រ/Demand deposit

េលខទូរស័ព�:Mobile phone No.

គណនីប័ណ�ឥណ�ន/Credit card account

(េសៀវេ�គណនីបេ��ើសំៃច/Passbook: �ទ/�ស/Yes េទ/No)


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ធនាគារ េអសុលីដី ភីអិលសុីACLEDA Bank Plc.

Personal Account Opening Application Form

ទ�មង់េបើកគណនីឯកត�ជន

សូមបំេពញែបបបទ�ងេ��មេនះឲ��ន�តឹម�តូវ និងច�ស់�ស់ Please fill in this application properly.

�នន�រ/Title:

េ��ះ��ែខ�រName in Khmer

េ��ះ�អក�រ��ំងName in Latin

Name in Khmer Name in Latin

ៃថ� ែខ ��ំកំេណើតDate of birth

ទីកែន�ងកំេណើត:Place of birth

�ងក��/Ms.េ�ក�សី/Mrs.េ�ក/Mr.

(ស��តិេផ�ង/Dual citizen: េទ/No �ទ/�ស/Yes: )

េទ/No �ទ/�ស/Yes: �ក់/Person(s)

ស��តិ:Nationality

មុខរបរ ឬមុខ�រProfession

�ម�តកូល:Surname


ព័ត៌�នអ�កេស�ើសុ/ំApplicant’s information

លិខិតស��ល់ខ��នType of legal ID

េសៀវេ��គួ�រ/Family bookលិខិតឆ�ងែដន/Passportអត�ស��ណប័ណ�/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


េលខ/Number: ៃថ�ផុតកំណត/់Expiry date:ៃថ�េចញ/Issued date:dd mm yy

/ /dd mm yy

/ /

Real estate businesses (incl. agents)

�សយ��នទំ�ក់ទំនងContact address

េលខទូរស័ព�/Mobile phone number: អីុែម៉ល/E-mail:

េលខ/េ��ះអ�រ/Building name or No.: េលខ/េ��ះផ��វ/Street name or No.: �កុមទ/ីGroup No.: ភូម/ិVillage:

ឃុំ/ស��ត់/Commune: �សុក/ខណ�/�កុង/District/City: េខត�/�ជ�ន/ីProvince/Capital:

Dealers in precious metals and stones Casino េផ�ងៗ/Other:

គណនីរួម/Joint account

ព័ត៌�នរបស់អ�ករួមគណន/ីJoint account's information

��ប់េស�េអសុីលី�យូនីធី�ន់ចិត�ACLEDA Unity ToanChet Registration




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ៃថ� ែខ ��ំកំេណើតDate of birthទីកែន�ងកំេណើត:Place of birth


(ស��តិេផ�ង/Dual citizen: េទ/No �ទ/�ស/Yes: )ស��តិ:Nationality






Politically exposed persons (PEPs)-Domestic Politically exposed persons (PEPs)-Foreign



េលខ/Number: ៃថ�ផុតកំណត/់Expiry date:ៃថ�េចញ/Issued date:

Money changers




េលខទូរស័ព�/Telephone number: អីុែម៉ល/E-mail:



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Form: 50-153 of 2

Enrolled Biometric

Remark:

Name:

Signature:

Name:

Signature:

Enrolled byDual controlled by

Name:

Signature:

Prepared byVerified by

Customer's photo number:

ស��ប់ធ��រ / 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�

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Customer's photo number: I M

I M

I M

Customer ID: Spouse Relative Friend Other:

Customer's photo number:

Jointaccountholder Spouse Relative Friend Other:Customer ID:

ខ��ំ/េយើងខ��ំអនុ��តឲ�ធ��រផ�ល់ព័ត៌�នគណនីរបស់ ខ��ំ/េយើងខ��ំេ��ធរ�ក់ព័ន� ។I/we authorized the bank to disclose my/our account information to the relevant authorities.

ខ��ំ/េយើងខ��ំអនុ��តឲ�ធ��រេ�បើ��ស់ព័ត៌�នរបស់ខ��ំ/េយើងខ��ំែដល�ន�មួយធ��រ េអសុីលី� ភីអិលសុី ដល់�កុមហ៊ុនបុ�តសម�័ន� និងៃដគូរបស់ធ��រ េអសុីលី� ភីអិលសុីេដើម�ីផ�ល់េស�ថ�ីៗដល់ខ��ំ/េយើងខ��ំ ។ 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.

�លបរ�េច�ទ/Date:ហត�េល� ឬ��មេមៃដអ�កេស�ើសុំនិង/ឬអ�ករួមគណន/ីApplicant’s and/or joint account holder’s signature or thumb print

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សន�ំ និងសុវត�ិ�ព�ច់��ក/់Savings for safety

សន�ំ��ក់ទទួល�ន�រ��ក់ខ�ស់/Savings for interest

សន�ំ��ក់ទិញផ�ះ-ដី/Savings for dream house

សន�ំ��ក់ទិញរបស់េ�បើ��ស់/Savings for buying personal appliance

�បតិបត�ិ�រ�ជីវកម� ឬទូ�ត់ទំនិញ/េស�កម�/Business operation or goods/service payment

ទទួល��ក់កម�ីនិងសំណងឥណ�ន/Loan disbursement and repayment

ទទួល��ក់េផ�រចូល-ក��ងនិងេ��បេទស/Receiving money either local or oversea transfer

បង់ៃថ��រសិក� និងអ�គតកុ�រ/Children education

សន�ំ��ក់ស��ប់េទសចរណ៍/Savings for travelling

សន�ំទុកចូលនិវត�ន៍-��ប័នឯកជន/Retirement-private institute

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េ�លបំណងេ�បើ��ស់គណនី (េរើស�នែតមួយ)/Purpose of using account (Only one selection):

�ទ/�ស/Yes េទ/No

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េធ�ើលិខិតអះ�ងេលើគណន/ីBank confirmation

េ�បើ��ស់ប័ណ�-�ន់ចិត�-IB-POS/E-banking services

េដញៃថ� និងេស�ហិរ��ប��ន�ណិជ�កម�/Bidding project and trade finance

ជួញដូរមូលប័�ត/Security trading

បង់ពន� ប័ណ��តង់ និងេស�ើសុំ��ប័ណ��ជីវកម�/Tari�/ patent/ business license

េផ�ងៗ/Other:17-

េ�បើ��ស់េស��៉ប់រង/Insurance

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ៃថ� ែខ ��ំកំេណើតDate of birthទីកែន�ងកំេណើត:Place of birth


(ស��តិេផ�ង/Dual citizen: េទ/No �ទ/�ស/Yes: )ស��តិ:Nationality






Politically exposed persons (PEPs)-Domestic Politically exposed persons (PEPs)-Foreign



េលខ/Number: ៃថ�ផុតកំណត/់Expiry date:ៃថ�េចញ/Issued date:

Money changers




េលខទូរស័ព�/Telephone number: អីុែម៉ល/E-mail:



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Personal Account Opening Application Form · Name in Khmer េ ះ អក រ ំង Name in Latin...

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Transcript of Personal Account Opening Application Form · Name in Khmer េ ះ អក រ ំង Name in Latin...