REMITTANCE MEMBERSHIP REGISTRATION and/or APPLICATION FOR REMITTANCE
WITH DECLARATION/

外国送金事前登録

送金依頼書兼告知書

I hereby authorize Philippine National Bank Tokyo Branch/Nagoya Sub-Branch (“PNB Japan”) to register my personal information and, upon actual
receipt of funds, to implement my remittances to the specific beneficiary registered. I hereby declare the required items pursuant to Article 3 of the “Lawon Reporting Requirements on Cross Border Payments and Receipts for the Tax Law compliance” as follows.

私はフィリピン・ナショナル・バンク東京支店/名古屋出張所（以下”PNB Japan”）に私の個人情報を登録し、資金受領の度に海外送金を実行することを依頼します。内国税の適正な課税の確保を図るための国外送金等に係る調書の提出等に関する法律第３条の規定により下記の通り告知します。
Additional Beneficiary 受取人の受取人の追加

First time Remitter 新規

既存送金人

Existing Remitter

REMITTER MEMBER NUMBER(for existing remitter)

訂正Amendments(For First time Remitter, please register by mail.)
注意事項：
注意事項：ご送金人名
送金人名も人名も含め、全てローマ字ローマ字または数字または数字で数字で記入してください
記入してください。してください。

・送金人情報 Nagpapadala

Remitter’s Information

・姓・名

Family Name

Name of Remitter

送金人名
送金人名

Indicate T or N

Middle Name (Fill-up in full)First Name

〒Address in Japan

郵便番号・現住所・携帯又は電話番号

Mobile / Telephone No.

E-MAIL Address e

メールアドレス

身分証明書
下記の身分証明書のコピーいずれか一つ提出してください。
Occupation
職業・外国人登録証明書（両面）・在留カード（両面）Type of Identification
Please submit copy of one of IDs below.
FOR FOREIGNERS:
Valid Alien Registration Card (both sides)
Valid Residence Card (both sides)

FOR JAPANESE:
Valid Japanese Driver’s License (both sides)
Valid Health Insurance (name/address/birthday pages)
Passport

・日本の運転免許証（両面）・健康保険証（名前/住所/生年月日）

・パスポート

Beneficiary’s Information

受取人情報・
受取人情報・ Pinapadalhan

Name of Beneficiary

受取人名(口座名義人)(Account Name)

Note:

Date of Birth誕生日□ Company employee
会社員□ Public employee
公務員□ Housewife
主婦□ Other (その他 (MM (月)DD(日)YY(年)))

Please register each and subsequent beneficiaries separately.

複数の複数の受取人をご受取人をご登録をご登録になる
登録になる場合になる場合は
場合は、受取人ごとに受取人ごとに本書式ごとに本書式に本書式に記入の記入の上提出してください
上提出してください。してください。
(1) SSS(2)

PAG - IBIG

From : _____________________

To : ___________________

Membership ID No.

Applicable Period of Payment

Currency of account

受取人口座通貨

Payment thru OBPSPurpose of Remittance

送金目的Real Estate Loan Payment(A) FUNDS for Remittance
Short Term Loan Payment

Contribution ( Monthly Amount ____________________ )Relationship to the Beneficiary

受取人との間柄

送金金額(B) Remittance FEE

取扱手数料(C=A+B)

BILLER

TOTAL

Peso Account
US Dollar AccountFor Bank Use only

¥10,0005,000¥2,0001,000¥

必要円貨総額

50010050
10I certify the information written above is true and hereby confirm that the General Provisions and Privacy Policy and Customer Data
Protection stated on the back page hereof will govern all remittances I undertake through PNB Japan. I hereby also declare that
I am not a member of anti-social forces and my remittance request is not related to the regulations under Foreign Exchange andForeign Trade Law in connection with North Korea and Iran.

上記記載事項が真正であることを申し立てるとともに、裏面記載の取引規約及び個人情報に関する規定を確認し同意いたします。
また、反社会的勢力でないことを表明すると共に、「外国為替及び外国貿易法」に規定する北朝鮮及びイランに関連する取引でないことも表明いたします。
Remitter’s Signature
ご署名または署名または記名押印
または記名押印

Date 日付BANK USE ONLYMMID & Number

Receivedby / DateDDID
Issuing dateRegistration
Approvedby:YY

銀行使用欄MMDDID ExpiryIDsEncodedby

1stcheckerof ID

YYMMDD

YYVisaExpiry

2ndcheckerof ID

Over 1.0 million
Approved by

Fulfillment ofConfirmation obligation by1 October 2013

GENERAL PROVISIONS APPLIED TO REMITTANCE TRANSACTIONS
1. Philippine National Bank Tokyo Branch / Nagoya Sub-Branch (“PNB Japan”) shall not be responsible for errors or delays in the domestic fund transfer or for inaccuracies in the instructions
provided, or for any other consequences arising from causes beyond its control. Nor is PNB Japan responsible for any consequential damages caused by errors or delays in transmission ornon-transmission.
2. Implementation of remittance shall be done in US dollars or Philippine Peso depending on whether the beneficiary account is in US dollar or Philippine Peso. For ‘advise and pay’ (over-thecounter payment) to the Head Office or branches of Philippine National Bank (“PNB”) and door-to-door delivery in the Philippines, remittance will be in Philippine Peso only.
The remittance proceeds shall be converted into Philippine Peso or US dollars by using TTS rate quoted by PNB Japan on the date when remittance requested by the client is implemented.
Note: Amounts printed in your receipts for remittances to PNB on-line (rapid remit) accounts are already net of charges. Amounts printed for non-PNB Peso accounts represent the amountto be forwarded to the other bank. The other bank may apply its own charges.
3. Cancellation or dismissal of the client’s remittance request : Even if PNB Japan was requested to make a remittance by the client, PNB Japan shall have its discretion not to do so under thefollowing cases :a. The purpose of the client’s remittance is against the Japanese Foreign Exchange Regulations.
b. War, civil commotion or some similar occasions will possibly prevent PNB Japan’s remittance to the beneficiaries or block PNB Japan’s funds in the Philippines or inJapan.
c. This remittance will possibly be subject to money laundering, which is mainly related to the drug, crimes, terrorism, etc.
In these cases, PNB Japan shall not be liable for any loss on the client’s side from PNB Japan’s non-remittance.
4. PNB Japan shall at any time have its own option or discretion for with which way PNB Japan shall use either by our on-line or through our correspondent banks, etc.
5. Contact information:a. In the necessity of any contact with the client, address or telephone number in the client’s application is regarded as contact information.
b. PNB Japan shall not be liable for any loss deriving from miscommunication due to the reasons that the client written address is incorrect or the client’s telephone
number is incorrect. Please keep updated transaction identification items and notify PNB Japan of any changes.
6. The Remitter Member Number should not be used by other person than the legitimate holder. If abuse was revealed, PNB Japan reserves the right to suspend immediately all thetransactions with such a Number.
7. When receiving a request for remittance, PNB Japan is required to ascertain certain matters under laws and regulations governing foreign exchange. The client is, therefore, required tosatisfy the following requirements :(i) State the purpose for remittance and any other required information in the Application for Remittance; (ii) State the designated items in the Application for Remittance (serve asDeclaration Form ) and submit it , except for cases such as when the funds of remittance are to be debited from the client’s account; (iii) Present the official documents to identify the client
such as original/copy of the client’s certificate of residence, except for cases such as when the funds of remittance are to be debited from the client’s account; and (iv) For any transactions
requiring Government permission or such, present or submit documents proving the said permission or such.
8. In order to effect overseas remittance requests, part of the client’s personal information, such as the client’s name, address and account number (if applicable), shall be disclosed to theconcerned paying/crediting bank as originator’s accurate and meaningful information.
9. In order to maintain compliance with Anti-money laundering controls and laws PNB Japan may, at its sole discretion, request additional information pertaining to the source of funds, prior to
the funds being sent. Failure to comply with this request may result in the client registration being either deactivated or cancelled and funds being returned to the client.
10. Any loss: PNB Japan shall not be liable for any loss deriving from these events:a. National calamity, war, any incident in transit, civil commotion, restriction by laws, emergency restriction by Government or by public body (Central Bank, etc.)
b. Failure of PNB Japan’s computer system under (within) the level that PNB Japan pays regular attention for its service, failure of telecommunication, failure ofcomputer system, or garble or mistake or omission of the words due to telecommunication.
c. As the result of following the procedure prevailing in the pertinent country or the special instruction by the specific paying bank.
d. Mistake in remittance details, e.g. beneficiary, account number, etc. by the client.
e. Messages to be sent to the beneficiary.
f. Legal dispute among remitter, beneficiary or the third party.
g. Any other loss other than PNB Japan’s own clear mistake.
11. Amendment or cancellation :a. If PNB Japan can determine that it can still be done, amendment or cancellation of an implemented remittance can be facilitated upon the client’s request.
Amendment or cancellation cannot be done once the funds are already withdrawn by the beneficiary.
b. This should be presented in the client’s written request duly signed by the client.
c. PNB Japan shall require the client to present a valid ID to properly establish the client’s identification.
d. On a case-to-case basis (subject to the amount, etc.), PNB Japan shall require the client to submit a guarantor to confirm the client’s action.
e. PNB Japan shall not be liable for any loss if it cannot amend or cancel due to non-acceptance of the paying bank, restriction of the law, emergency restriction by thegovernment or by public body (Central Bank, etc.)
f. The client is requested to pay a follow-up fee of JPY2,500 per item. Follow-up fee may be subject to change.
g. For amendment of remittance, original rate used will prevail. As for cancellation, yen equivalent using the PNB Japan’s buying rate of the day when the exact fund isreceived from concerned paying/crediting banks, less their charges will be the refund amount.
12. Non-arrival of the client’s remittance: If the client finds that its remittance did not reach the beneficiary, please let PNB Japan know at the soonest so that PNB Japan shall trace immediately
and inform the client of the result in due course.
13. Matters not stipulated herein shall be governed by laws, regulations, customs and practices of Japan and other relevant countries and the procedures prescribed by the banks concerned.
14. Designated Dispute Resolution Institution contracted with PNB Japan is Japanese Bankers Association. Contact point:: Japanese Bankers Association Customer Relations Center
Phone number: 0570-017109 or 03-5252-3772

PRIVACY POLICY AND CUSTOMER DATA PROTECTION
To be a bank that enjoys the confidence of its customers and is the customers' bank of choice, PNB Japan observes the relevant laws and ordinances as well as the other standards relating
to customer's personal information, conforms with the various regulations, etc. of PNB Japan that relate to personal data protection, and makes every effort to conduct appropriate management
and maintain accuracy and confidentiality in line with the following :1.

PURPOSES OF USE OF INFORMATIONPNB Japan acquires the personal information of customers so that our transactions with customers progress securely and soundly and so that customers can be provided with better
financial products and services. In concrete terms, the information is used for such purposes as checking the identity of a person, checking conditions for doing business, andintroducing new products and services to the customer.

2.

TYPES OF INFORMATION TO BE ACQUIREDThe most general types of information to be acquired are the address, name, date of birth, sex, and the telephone number of the customer. In addition to these types is the information
requested from the customer when transactions are commenced.

3.

PROVISION OF INFORMATIONPNB Japan shall not externally provide customer information except in the following cases:••

Where the customer has consented.
Where the situation comes under the exception cases which are stipulated by a law or ordinance.

4.

INFORMATION MANAGEMENT METHODAppropriate measures are constantly taken so that customer information can be kept accurate and up-to-date. In addition, to prevent the loss, destruction, falsification, and leaking, etc.
of the personal data of customers, PNB Japan takes appropriate information security measures such in addition; PNB Japan ensures that any company handling the personal data ofcustomers, etc. on consignment from PNB Japan also enforces rigorous management.

5.

CUSTOMERS' APPLICATIONS FOR DISCLOSURE, CORRECTION OR DISCONTINUATION
Unless there is a particular reason, PNB Japan approves customer requests for disclosure of their own information after PNB Japan checks that the applicant is the person concerned. Inaddition, if the information about the customer is inaccurate, PNB Japan modifies it so that it is accurate. Application should be made at the inquiry desk detailed below. Please note thatactual costs may be billed for disclosure. PNB Japan shall advise the customer of the amount of the actual costs in advance if the actual costs are billed.
Discontinuation of Promotional Materials
To continuously update clients of new products and services, PNB Japan shall insert flyers, advertising materials and the likes in the mails it sends out. If the client wishes todiscontinue, please contact and advise PNB Japan.

6.

CUSTOMER INQUIRIES AND COMPLAINTS
The customer may contact the person-in-charge as provided on the list below for inquiries, complaints, and requests for disclosure, correction of data and discontinuation of the use ofpersonal information to the address mentioned below.
Philippine National Bank, Tokyo Branch
Personal Data Protection Manager
Tel. 03-6858-5910 Business Hours: 9:00 to 15:00 (Excluding weekends, Japanese Public Holidays and the year-end/New Year business holidays.)
Philippine National Bank, Nagoya Sub-Branch - Personal Data Protection Manager
Tel. 052-968-1800

7.

MODIFICATIONS
The above information may be modified as a result of amendments to the law and other reasons. In that case, a notice will be posted at the PNB Japan’s premises.

1 October 2013
Philippine National Bank Tokyo Branch

フィリピン・ナショナル・バンク東京支店〒108-0073 東京都港区三田 3-13-16 三田 43MT ビル 1 階

Philippine National Bank Nagoya Sub-Branch〒1/F MITA43MT Building, 3-13-16 Mita, Minato-ku, Tokyo Japan 108-0073
Tel: (03) 6858-5910 Fax: (03) 6858-5920
Mobile phones (Softbank): 080-3724-4544 / 090-4066-0980
Rates Info: (03) 6858-5940/6858-5950 rate@pnbtokyo.co.jp
Url: www.pnb.com.ph/japan
E-mail: customercare@pnbtokyo.co.jp

フィリピン・ナショナル・バンク名古屋出張所〒460－0003 愛知県名古屋市中区錦 3－24－24 錦 324 ビル７階

7F Nishiki 324 Building, 3-24-24 Nishiki, Naka-ku, Nagoya-shi, Aichi-ken

Tel: (052) 968-1800 Fax: (052) 968-1900
Rates Info: (052) 968-1101
E-mail: pnbnagoya@pnbtokyo.co.jp