CREDIT CARD REQUEST FORM
Please completely fill out all mandatory* information below.
CARDHOLDER DETAILS
CARDHOLDER’S NAME*:
CARD NUMBER*: EXPIRY DATE*:
UPDATED BILLING ADDRESS*:
HOME PHONE NUMBER*: OFFICE / BUSINESS PHONE NUMBER*: BEST TIME TO CALL*:
AM
FAX NUMBER*: MOBILE NUMBER*: 0 9 PM
E-MAIL ADDRESS*:
Increase in Credit Limit Cash Advance (over the counter)
Please complete the following details: Card Number:
Nature of Business / Employment: Amount:
Position: Approval Code:
Monthly Income (please attach income documents):
BPI/BFB Accounts:
Cash Advance PIN Request
Bank: Account Number:
Card Number:
Credit Card/s with other bank/s:
Credit Card Company: Credit Card Number:
Extension, Link, Conversion, Replacement
Market Segment:
Permanent Extension / Supplementary Card
Name*:
Present Credit Limit
Requested Credit Limit Gender*:
Birth Date*:
Temporary Place of Birth*:
Present Credit Limit Civil Status*:
Requested Credit Limit
Nationality*:
From (mm/dd/yyyy)
Relationship to PCH*:
To (mm/dd/yyyy)
Present Address*:
VS Hold Out Express Start (Client should sign new DOA) Permanent Address (*if different from Present Add):
Current Amount on Hold Contact Details*:
New Amount on Hold Email Address:
Home / Mobile / Office No.:
Reallocation of Credit Limit Employment Code / Type* (Please refer top table at the back portion of this form):
Card Number Name of Employer / Business (*If Employment code is Employed or Self-Employed):
Present Credit Limit Position (*If Employment code is Employed, Self-Employed or Passive Income Earner):
Requested Credit Limit Nature of Employment / Business (*If Employment code is Employed or Self-Employed):
Source of Funds*:
Decrease in Credit Limit TIN Number (*If Employment code is Employed or Self-Employed):
SSS/GSIS Number (*If Employment code is Employed or Self-Employed):
Card Number
Present Credit Limit Link Card
Requested Credit Limit CARD TYPE REQUESTED:
REGULAR GOLD (at least 75K) PLATINUM (at least 150 K)
BPI BLUE MASTERCARD BPI GOLD MASTERCARD BPI SKYMILES MASTERCARD PLATINUM
Dispute Card Transactions
PETRON-BPI MASTERCARD BPI AMORE VISA PLATINUM
Please refer to the specified Dispute Forms (Form 1 or Form 2) via DTAS BPI EDGE MASTERCARD
BPI E-CREDIT
Reversal of Fees BPI SKYMILES MASTERCARD
BPI AMORE VISA
Reason
Date of Statement of Accounts Card Conversion (OLD CARD)
Total Amount Existing Card Type
Breakdown: Card Number
Annual Fee CARD TYPE REQUESTED:
REGULAR GOLD (at least 75K) PLATINUM (at least 150 K)
Finance Charge
BPI BLUE MASTERCARD BPI GOLD MASTERCARD BPI SKYMILES MASTERCARD PLATINUM
Penalty
PETRON-BPI MASTERCARD BPI AMORE VISA PLATINUM
Other Fees (Please indicate) BPI EDGE MASTERCARD
BPI E-CREDIT
Refund of Overpayment BPI SKYMILES MASTERCARD
Reason BPI AMORE VISA
Last Payment Details:
Replacement (with Php 400 replacement fee)
Date of Payment
Amount Card Number
Payment Channel Branch Express Online Others (please specify) Reason for Replacement
Change in Cardholder’s Information Card Cancellation
Status / Name: Reason:
____ w/ card replacement (with Php 400 replacement fee)
____ w/o card replacement ALL PRIMARY AND LINK CARDS under this customer number
Please attach the required documents (Photocopy):
____ MARRIAGE CONTRACT Selected credit card number/s listed below:
____ ANNULMENT PAPERS
Cardholder Name Credit Card Number
____ VALID ID, for change in name only if card tenure is more than 1 year.
Preferred billing address
Residence Office
From:
To: Express Start Cancellation
Telephone number REQUEST TYPE (Please check the appropriate box)
Residence Office Full Release of Holdout with Card Retention
From: Full Release of Holdout with Card Retention and ICL
To: Partial Release of Holdout with Card Retention
Full Release of Holdout and Card Cancellation
Mobile number
From: If existing cardholder with other bank/s:
To: Credit Card Company: Credit Card Number:
E-mail address
From:
To:
HOLD-OUT ACCOUNT(S) (List all active accounts in full hold. CHECK box if for release)
Cut-off / billing cycle
From: Acct 1 Type & Number Hold-out Amount
To: Acct 2 Type & Number Hold-out Amount
Acct 3 Type & Number Hold-out Amount
Lost Card
Card Number: Statement of Account Enrollment Type
Card Reactivation eStatement Paper Statement of Account EOL Viewing only
Card Number: Card Number:
For Branch Use only:
NOTE: This is for documentation purposes only. All requests must be sent via DTAS.
Client’s Signature over Printed Name: Verified by: Processed by:
As of June 2015
NATURE / TYPE OF EMPLOYMENT / BUSINESS / PROFESSION
ACT - Accounting / Bookkeeping / Tax Practice / Services LAW - Lawyer
ADS - Advertising / Marketing / Sales Activities LEG - Legal Practice
AGR - Agriculture / Hunting / Forestry / Animal Farming / Fishing LSE - Leasing / Rental Activities (e.g., land, building, machinery, etc.)
ARC - Architect MED - Medical Service (includes caregiving)
BHS - Beauty and Health services (e.g., spa, beauty parlors, fitness centers) MFG - Manufacturing (Non-Food, e.g., garments, vehicles, jewelry, heavy equipment, etc.)
BNK - Banking MIL - Military-NP
BPO - Business Process Outsourcing (e.g., Call Centers, Billing / Credit / Collections, etc.) MIN - Mining
BRO - Brokerage MNF - Manning or Employment Agencies – Foreign
CHA - Charities MNL - Manning or Employment Agencies – Local
CMT - Commodities Trader NGO - Foundation (NGO)
COM - Communication (Telecommunications includes postal) OPS - Other Professional Services (e.g, Delivery, Photography, Catering, Interior Design, Fashion Design Styling, etc.)
CSY - Consultancy (e.g., computer-related consultancy-hardware / software, technical engineering / architectural, scientific-related consultation, PUB - Publishing / Printing / Reproduction of Recorded Media
business consultation) PWN - Pawnshop
CTN - Construction (e.g., building, plumbing, electrical, carpentry) RCY - Recycling
DOC - Doctor / Dentist REL - Real Estate (e.g., development, sales, etc.)
EDU - Education (including private tutorials, special education) REM - Remittance Agent
EMB - Embassies / Foreign Consulates REO - Religious Organization
ENG - Engineer REP - Repairs Services (e.g., machinery, automobiles, television, cellphone, etc.)
ENT - Entertainment (Recreational / Cultural / Sporting Services (e.g., party planning services, event organizing, carnival SAN - Sanitation / Cleaning / Housekeeping Services (e.g., janitorial services, building maintenance, laundry, etc.)
rides rental, fireworks displays, media network, film productions, etc.)) SHP - Maritime or Shipping
FDI - Food Industry / Food Manufacturing / Food Preparation / Processing / Food Packaging TOU - Tourism (e.g., Hotels, Inns, Resorts, Tour agencies, Restaurants)
FIN - Financial Services TRA - Wholesale / Retail Trade
FXD - FX Dealer / Money Changer TRN - Transport (Air, Water, Land)
GAC - Gaming Clubs / Casino UTI - Utilities (Electricity, Gas & Water Supply)
GOV - Government Service-NP WAT - Collection, Purification & Distribution of Water
INS - Insurance Activities OTH - OTHERS
Branch Annual Membership Fee Reversal Request Form
AMF Reversal Request Form
This is to request for the annual membership waiver of: January 2016
Principal Cardholder's Name:
Card number/s to be requested for reversal:
□ Principal □ Supplementary
□ Principal □ Supplementary
Please indicate if card is principal orsupplementary □ Principal □ Supplementary
□ Principal □ Supplementary
□ Principal □ Supplementary
Date of Request:
Please be reminded that the waiver of annual membership fee is subject for approval and reversal is not guaranteed upon request. For now, kindly settle your current statement balance including the Annual
Membership Fee to avoid unnecessary charges.
□ This is to acknowledge that the Branch personnel has discussed with me the details needed to process the reversal of my annual membership fee.
Requested by:
___________________________
Cardholder’s printed name and signature
______________________________________________________
To be accomplished by the Branch:
□ □
Requirement to be fulfilled:
None Spend Condition
□ EOL Activation & Paper SOA Suppression
□ Exception Handling
□ Supplementary Card
Please remind clients to settle their outstanding balance including the Annual Membership Fee to avoid unnecessary charges while waiting for the status of their request.
□ This is to acknowledge that I have discuss ed the requirements needed to process the client’s reversal and he/she has agreed to do the requirement checked above.
Endorsed by:
____________________________
Branch Personnel’s printed name and signature
