FORMULIR PEMBUKAAN REKENING TABUNGAN NASABAH BARU

Nomor Rekening : Tanggal:

A. DATA UMUM (DIISI DENGAN HURUF CETAK )

Nama Lengkap : ......................................................................................................................................................................

Nama Ibu Kandung : ......................................................................................................................................................................
Alamat Sesuai Dg Tanda Pengenal : .....................................................................................................Kelurahan ................................................
Kecamatan ............................................ Kota ...............................................Kode Pos : ..............................
Alamat Sekarang : .....................................................................................................Kelurahan ................................................
Kecamatan ............................................ Kota ...............................................Kode Pos : ..............................
No. Telpon/HP :.......................................................................................................................................................................
Nama Kantor/Tempat Kerja :.......................................................................................................................................................................
Alamat Kantor : .....................................................................................................Kelurahan ................................................
Kecamatan ............................................ Kota ...............................................Kode Pos : ..............................
No. Telpon :.......................................................................................................................................................................
Jabatan :.......................................................................................................................................................................
Mulai Bekerja : bln thn
Kewarganegaraan : WNI WNA
Jenis Kartu Identitas : KTP SIM Pasport Lainnya .......
No. Kartu Identitas : ............................................................ Berlaku s/d
Tempat Lahir : ............................................................ Tanggal Lahir
Agama : Katolik Kristen Hindu Budha Islam
Pekerjaan : Pelajar/Mhs Ibu RT Pegawai Negeri Karyawan/ti swasta
Wiraswasta Lainnya ................

Jenis Kelamin : Laki – Laki Perempuan

Status Perkawinan : Belum Kawin Kawin Lainnya.......
Penghasilan / Bln : < 500.000 500.000 – 2.000.000 2.000.000 – 10.000.000 >10.000.000
NPWP : Ada Tidak Ada
Nomor :
Sumber Dana : .....................................................................................................................................................................
Demikian Permohonan ini dan kami nyatakan akan mematuhi ketentuan yang berlaku di Bank.

Kertak Hanyar

( .............................................................. )
Nama & tanda tangan Nasabah

B. KHUSUS BADAN USAHA (PT. KOPERASI, YAYASAN )

No. Pengesahan Kehakiman/No.Akte Pendirian/No. Anggaran Dasar :
Tgl. Pengesahan Kehakiman/Tgl. Akte Pendirian/Tgl. Anggaran Dasar: Tgl. Bulan Tahun
Bidang Usaha atau Kegiatan : .......................................................................................................................................
Alamat kedudukan : .......................................................................................................................................
Susunan Direksi/Pemegang Saham/Pengurus :
...............................................................................................................................................................................................................................
..............................................................................................................................................................................................................................
Maksud & Tujuan hubungan usaha atau transaksi yang akan dilakukan calon nasabah : ...................................................................................

REKENING DIBANK LAIN

Nomor Rekening Nasabah :

Jenis Rekening :
Bank :
Kantor Cabang :
Sejak :

DIISI OLEH BANK

Nomor Rekening :
Nomor Register :
Kertak Hanyar :

Petugas : Diketahui Oleh :