F*rrn-KA
t social trstr arni ffi ank Ltd
s*rur-*n. r*** ru, n#ffi# frunuu nu n,
Date :
Ttre }vlana,gen
lio*ial flslarni Bank [-tcl
.....Branch
hu[u]riararrr^
Assalanru Alaikr:m.
,i
fuIyl0ur Account mentioneetr brelow inclu,ding
lrlame/Aic Tirie
AccoLrnt i!tl.
Chq ltiu & Dare
Purp*sc 0f Renrittarlce
Contect l\* S:ource ut':Fund
l\anrei AIC 'J'itle
Accrnnt Ila,
Contact r\o. Tk.
Bank Hame Rou,tittg, Con:nnissiorr
Branch hlamr No.
Vi\l
Total Tk.
IiWc eio hereby declare that the infbrmation given above is true to my/our k*owledge and I/we will be held
responsible for any deviatiol.
%,.,> ;"'"
Applicant/ customer's 2"d Applicant/customer's signature verinea uy."-.-"..:
signature & seal signature & seal (rfjoint) (Lrse,leal wjrh As No.)
For Bsflk tlsq Oqlr:
Authorized Officsr{iv{aker) Authorired Officer('Checker) tI$ad sf. SranuU 'Maxftgsr S.perati*ns
Signarure & AS No Signatur* & AS No
H'q,p.&e*'t,$qMoluJ##.semg3,f&r,,RT#,$"3.r,+nsagtlox
AcknolvleclgecJ that So*ial Islami ffiank l*t<j,). r, . r..,. .Bran,c}: tras received
Tk. , r,,. . .,.(Inworcls:"... r. ^ r. r {..
From lvlr./Mrs./Ms. i , .. . ... . . .,. ro.'k;;;i;*i;; *r,.-,,sh Rrci -#il},
to. ,Bank. . ., Braneh favouring Accor:nt
Narue. " . ^ , ancl AIC lJo. ,. +. r i ^ r. r
$rgr rature rrf Cusfornt:r Sigrrature & AS ttro of Authi--rized Otficial
NB : ii:irrmplete Application treateri as uivalid
N-*= -.*.-:-
