REMITTANCE MEMBERSHIP REGISTRATION and/or APPLICATION FOR REMITTANCE
WITH DECLARATIONFor Individual 個人用
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。
First time Remitter 新規
Existing Remitter

既存送金人

Additional Beneficiary

受取人の追加Amendments

訂正

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

Indicate T or N

Remitter’s Information・送金人情報 Nagpapadala

Name of Remitter
送金人名

Family Name・姓

Middle Name (Fill-up in full)First Name・名〒Address in Japan
郵便番号・現住所

E-MAIL Address e メールアドレス

Mobile / Telephone No.・携帯又は電話番号

Type of Identification
身分証明書
Please submit copies of two IDs below. 下記の 2 つの身分証明書のコピーを提出してください。

□Occupation
職業FOR FOREIGNERS: Residence Card is mandatory

Valid Residence Card (both sides)
My Number Card (both sides) or□

My Number Notification Card□

FOR JAPANESE: 運転免許証かパスポートおよびマイナンバーが必要です。
Valid Japanese Driver’s License (both sides) ・日本の運転免許証（両面）Passport・パスポート
My Number Card (both sides)・マイナンバーカード（両面）または通知カード

Beneficiary’s Information

Date of Birth
誕生日

MM (月)

DD(日)))

YY(年)

Note: Please register each and subsequent beneficiaries separately.
複数の受取人をご登録になる場合は、受取人ごとに本書式に記入の上提出してください。

受取人情報・ Pinapadalhan

Name of Beneficiary□

Company employee
会社員
Public employee
公務員
Housewife
主婦
Other (その他 (Family Name ・姓

Middle Name (Fill-up in full)First Name・名(Account Name)

受取人名(口座名義人)
Mobile/Tel. No.・携帯又は電話番号

Beneficiary's Address
受取人住所
Branch Name ・支店名

Bank Information

Bank Name・銀行名

受取人取引銀行・支店名□ PNB □ Others __________□ Instapay (for credit to other Philippine bank account)
Please see reverse and read General Provision No. 2

Peso Account
US Dollar Account
JPY AccountAdvise & Pay / Over-the Counter Payment（通知後窓口払）
Door to Door （宅配便による配達）I would like to request for the opening of OFW account for my beneficiary in the Philippines

Account Number

Currency of account
受取人口座通貨

受取人口座番号*If no account口座がない場合

Purpose of Remittance 送金目的
Family Support 家族送金

Deposit (Savings/ Time) 預金

Import Settlement 輸入決済

Others (Pls. specify) その他()

Relationship to the Beneficiary
受取人との間柄For Bank Use only(A) FUNDS for Remittance
送金金額¥(B) Remittance FEE
取扱手数料¥(C=A+B)

10,000
5,000
2,000
1,000

TOTAL¥必要円貨総額

If you want to avail Postal Link or Virtual Access on your next remittance using Beneficiary details
stated above, please tick the box. Your consent to T&C (the 1st page of Application Form) needs
to be submitted together with this form. 上記受取人情報に基づき”バーチャル・アクセス”あるいは”ポスタ

500
100

□
□50
10

ル・リンク”の申込みをご希望の場合はチェックマークをお願いします。登録申込書と一緒にご提出ください。

I certify the information written above is true and hereby confirm that the General Provisions and Privacy Policy and Customer Data Protection andAgreement on declaration and undertaking in regards to elimination of Anti-Social Forces stated on the back page hereof will govern all remittances I
undertake through PNB Japan. I hereby also declare that my remittance request is not related to the regulations under Foreign Exchange and Foreign
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及び反社会的勢力ではないことの表明・確約に関する同意を確認し同意いたします。また、「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
ご署名または記名押印

Date 日付BANK USE ONLY 銀行使用欄
ID Name orID Number

Received by /DateID/VisaExpiry

Registration
Approvedby:IDs
Encodedby

1stcheckerof ID

MMDD

2ndcheckerof ID

YYForex Article17 (North Korea and Iran)confirmed by

Over 1.0 million
Approved byFulfillment ofConfirmation obligation by

01 June 2021

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.
For remittances using Instapay service: In case the Client opted to remit funds using the Instapay service, and the system experiences a system time out during the processing of such
remittance, PNB Japan shall, within two (2) Philippine banking days from system time out, determine whether the said remittance transaction was successful or not. After the said period,
should PNB Japan determine that the remittance was unsuccessful, PNB Japan shall reprocess the remittance as a new transaction.
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 in Japan.
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 of computer system, orgarble 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 the government 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 is received fromconcerned 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 tocustomer'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 INFORMATION: PNB Japan acquires the personal information of customers so that our transactions with customers progress securely and soundly and so thatcustomers 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 fordoing business, and introducing new products and services to the customer.
2. TYPES OF INFORMATION TO BE ACQUIRED: The most general types of information to be acquired are the address, name, date of birth, sex, and the telephone number of thecustomer. In addition to these types is the information requested from the customer when transactions are commenced.
3. PROVISION OF INFORMATION: PNB Japan shall not externally provide customer information except in the following cases: Where the customer has consented or Where thesituation comes under the exception cases which are stipulated by a law or ordinance.
4. INFORMATION MANAGEMENT METHOD: Appropriate measures are constantly taken so that customer information can be kept accurate and up-to-date. In addition, to prevent theloss, destruction, falsification, and leaking, etc. of the personal data of customers, PNB Japan takes appropriate information security measures such in addition; PNB Japan ensures thatany company handling the personal data of customers, 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. In addition, 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 that actual costs may be billed for disclosure. PNB Japan shall advise the customer of the amount of the actual costs inadvance 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 andthe likes in the mails it sends out. If the client wishes to discontinue, 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, correctionof data and discontinuation of the use of personal information to the address mentioned below.
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.

Agreement on declaration and undertaking in regards to elimination of Anti-Social Forces
I (1). I declare that I am not a person who has fallen under any of the following categories: ① an organized crime group (Boryokudan),② a member of an organized crime group, ③. a quasi-member of a organizedcrime group, ④ a related company or association of an organized crime group, ⑤ a corporate racketeer, ⑥ other equivalent person of any category above, in the last five (5) years (such person referred to as the“OCGs”) ,and that I shall not fall any of OCGs. I further ensure that I have not fallen under in the last five (5) years and shall not fall under any of the following categories:
１． 1. A person having such relationship with the OCGs that shows the OCGs’ control over the person’s management;
２． 2.A person having such relationship with the OCGs that shows the OCGs’ substantial involvement in the person’s management;
３． 3.A person having such relationship with the OCGs that show reliance on the OCGs for the purpose of unfairly benefiting itself or third parties, or of damaging third parties;
４． 4.A person having such relationship with the OCGs that shows provision of funds, benefits or services from the person to the OCGs; or
５． 5.A person where any of the board members or other personnel substantially involved in its management is engaged in socially condemnable relationship with the OCGs.
(The(“Anti-Social Forces” means a person that falls within OCGs or any categories of Item 1 to 5 through above.)(2). I declare that myself or through the use of third parties has never conducted or will not conduct any of the following actions:
1. A demand with violence;
2. An unreasonable demand beyond its legal entitlement;
3. Use of intimidating words or actions in relation to transactions;4.An action to defame the reputation or interfere with the business of PNB Tokyo Branch by spreading rumor, using fraudulent means or resorting to force; or
5.Other equivalent actions of above.
(3). In the event PNB Tokyo Branch determines that it is not appropriate to maintain business transactions with you after becoming aware that the representation and warranties in this Article (1) and( 2) are notor had not been true or that I breached the covenants in this Article, all obligations of I owed to PNB Tokyo Branch shall become due and payable and I shall immediately repay such obligations upon demand
fro from PNB Tokyo Branch(4). I shall not claim for any damages incurred by you or any party in connection with the application of Article (3). I shall compensate for all damages incurred in PNB Tokyo Branch.

Philippine National Bank Tokyo BranchPhilippine National Bank Nagoya Sub-Branch

フィリピン・ナショナル・バンク東京支店

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

〒108-0073 東京都港区三田 2-11-15 三田川崎ビル 2 階
2F Mita-Kawasaki Bldg, 2-11-15 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

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

Tel: (052) 968-1800 Fax: (052) 968-1900Mobile phone (Softbank): 080-3601-6240
Rates Info: (052) 968-1101
E-mail: pnbnagoya@pnbtokyo.co.jp