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Lloyds TSB Bank plc, ATT, New Tower (5F), 2-11-7 Akasaka, Minato-Ku, Tokyo 107-0052.
Applicant ID: 120967
www.golloyds.com
GOLLOYDS OVERSEAS REMITTANCE ACCOUNT APPLICATION GoFamily Name First Name Middle Name Date of Birth Nationality Occupation
Mendoza
Gabriel
Evora
1979/07/20
PHILIPPINES
Business Development Analyst) )
Home Address
Must be current and match Alien Registration Card/Drivers License
Tel Fax Mobile E-mail
( (
Unit 105, Leo Palace 21, 4-12-22 Goshikiyama, Tarumi-ku Kobe-shi Hyogo-ken,655-0035Company Name and Address
080-5076-1979 [email protected]
WeServ Systems Ltd. 3/F Manulife Place 4-20-1 Kamata Ota-ku Tokyo-to,144-0052Fax ( )
Tel Fax
( (
03
) )
5480
8507
Advice of Transfer to be received by
x Mail - Home
Please check (only one) the bank you wish to use to make the domestic transfer (Furikomi) to us (typically the bank at which you hold your Yen account). TSB Sumitomo Mitsui Other To open a GoLloyds account foreign residents are required to provide photocopies of two of the following:
How did you learn about this service? Go Which paper Which magazine Which website Search engine Google Other Introduced by Keyword
x Mizuho
Tokyo Mitsubishi
Signature or seal /M D Y
Go
Current Alien Registration Card (both sides) Japanese Drivers Licence Passport (photo page)
Please remember to include copies of 2 pieces of ID
a) I hereby confirm that the terms and conditions attached will govern all remittances I undertake through Lloyds TSB Bank using my GoLloyds Overseas Remittance Account. b) I declare all information given is correct. If the purpose of an individual remittance is different from that stated, I shall make a supplementary purpose declaration to The Bank at the time of remittance.
a) TSBGo b)
Items marked with a square must be completed Source of income/wealth Expected number of transfers per year Expected total remittance amount per year (Yen)
Salary
9-12
1-2 million
1.
Beneficiary Name
Christine Mendoza
Beneficiary Bank and Branch Address
Beneficiary's current country of residence (if other than yourself)
Beneficiary's relationship to yourself (if other than yourself)
Philippine National Bank Makati Poblacion Branch, Angono cor. Cardona St., JP Rizal, Makati
PHILIPPINES
Spouse
Purpose of Remittance
Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.)
RemittancePlease be specific. e.g. if purchasing goods, please indicate what kind of goods
Account number
Currency of Transfer
Special Instructions
PNBMPHMM
27530300019
US DollarYen
If you wish to add more beneficiaries, please use the space provided on the next page.
2.
Beneficiary Name
Beneficiary Bank and Branch Address
Beneficiary's current country of residence (if other than yourself)
Beneficiary's relationship to yourself (if other than yourself)
Purpose of Remittance Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.) Please be specific. e.g. if purchasing goods, please indicate what kind of goods Account number Currency of Transfer Yen Special Instructions
3.
Beneficiary Name
Beneficiary Bank and Branch Address
Beneficiary's current country of residence (if other than yourself)
Beneficiary's relationship to yourself (if other than yourself)
Purpose of Remittance Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.) Please be specific. e.g. if purchasing goods, please indicate what kind of goods Account number Currency of Transfer Yen Special Instructions
4.
Beneficiary Name
Beneficiary Bank and Branch Address
Beneficiary's current country of residence (if other than yourself)
Beneficiary's relationship to yourself (if other than yourself)
Purpose of Remittance Bank/Branch No. (eg. ABA No., Sort Code, BSB No., IBAN No.) ABA No., BSB No., IBAN No.) Please be specific. e.g. if purchasing goods, please indicate what kind of goods Account number Currency of Transfer Yen Special Instructions