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A Remittance Subsidiary of the Philippine National Bank REMITTANCE APPLICATION FORM Remitter s Information Complete Name Date Complete Address Postal Code Tel. No/s E-mail Address Birth Date mm/dd/yy Identification Driver s License Passport Citizenship ID No Permanent Card Expiry Date mm/dd/yy Occupation Recipient s Information Employer Name/Address Others Issuing Authority Check box if recipient is same as the remitter. If different pls. indicate details below. Relationship to Sender Mobile No Remittance Instruction check one that applies Credit to PNB Account or GFMC indicate acct. no or GFMC no. here Availment of GFMC Door to Door Pick-up Credit to Other Bank indicate bank details below Bank Name Account Number Consent is given to PNB Global Remit to disclose this information to Law Enforcement Authorities if required* I also hereby certify that the foregoing information is true and accurate to the best of my knowledge. Signature over Printed Name and Date mm/dd/yy Branch Name Acct Currency Php/US Received by Printed Name and Signature of PNB Representative. If different pls. indicate details below. Relationship to Sender Mobile No Remittance Instruction check one that applies Credit to PNB Account or GFMC indicate acct. no or GFMC no. here Availment of GFMC Door to Door Pick-up Credit to Other Bank indicate bank details below Bank Name Account Number Consent is given to PNB Global Remit to disclose this information to Law Enforcement Authorities if required* I also hereby certify that the foregoing information is true and accurate to the best of my knowledge. no or GFMC no. here Availment of GFMC Door to Door Pick-up Credit to Other Bank indicate bank details below Bank Name Account Number Consent is given to PNB Global Remit to disclose this information to Law Enforcement Authorities if required* I also hereby certify that the foregoing information is true and accurate to the best of my knowledge. Signature over Printed Name and Date mm/dd/yy Branch Name Acct Currency Php/US Received by Printed Name and Signature of PNB Representative. If different pls. indicate details below. Relationship to Sender Mobile No Remittance Instruction check one that applies Credit to PNB Account or GFMC indicate acct. no or GFMC no. here Availment of GFMC Door to Door Pick-up Credit to Other Bank indicate bank details below Bank Name Account Number Consent is given to PNB Global Remit to disclose this information to Law Enforcement Authorities if required* I also hereby certify that the foregoing information is true and accurate to the best of my knowledge. Signature over Printed Name and Date mm/dd/yy Branch Name Acct Currency Php/US Received by Printed Name and Signature of PNB Representative.

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