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ACCOUNT OPENING FORM - NEW CUSTOMER

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Branch Name:
Relationship Type:

jSCG

Aspire

Privilege Club

jH Of

cEG

Excellency

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Please complete in BLOCK CAPITALS.

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Mr

IdG

Mrs

fBG

Ms

iNCG

Other

Name

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Passport No.

Section 1

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Yes

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?("OQc jL" jeCG IG jdG

y y y y

No

Country of Birth
Are you liable to pay

Yes

taxes in the U.S.?

No

Correspondence Address:

..U

P.O. Box

HdG /jdG

Floor/Building

City/ Emirate

IQeEG /jG
(e) Jg
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Tel. (Res.)
Mobile

Street/Dep./Area

Country
Tel. (Off.)
E-mail

Your Residential Address:

jdG SG

Building Name

Villa/ Flat No.

Street No., Name/Land Mark

IQeEG /jG

City/ Emirate

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Country

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Please ignore section 2 if you are the secondary account holder.

Type of Account:

Oa

Single

. bQ

Joint

G Uh

S. No.

Ub

Minor

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Product Description

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GQeEG jg bH bQ
GhdG b CG SG
OG e /H
FGV aH e fCG g

?jeCG IG jdG
:SGG GY
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(Y) Jg
hdEG jH
:dG GY
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I eY bCG /SG ,QdG bQ

EIDA Card No.

Mothers Maiden Name

Date of Birth
Are you a US Person
(US Passport or Green
Card Holder)?

:bdG f

Currency

iNCG

Other

:G f

Conventional

Islamic

eSEG

GeCG Qe

gQO

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Amount in Figures (AED)

Section 2

How will you be funding your new account(s)?

Cash

Gk f

Draft/Cheque

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2 dG

Source of Funds

Transfer

IjG HG/jG G j c
(fEG EG) OG V jY bQ

Etihad Guest Number (if applicable)

Cheque book required (AED current account only)

Yes

No

(a QeEG gQO H jQG HG) T aO e

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Name to appear on Debit Card

(k aM 19 M)

(up to 19 characters)

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Name to appear on supplementary Debit Card

He fc EG (k aM 19 M)

(up to 19 characters) if required

Acknowledgment/Declaration
I hereby irrevocably and unconditionally declare that all information provided
herein is true and accurate and authorize ADCB to verify all or any of such
information, from whatever sources it considers appropriate, and am aware of,
and agree to be bound by, the General Terms and Conditions for Account
Operation or relevant Terms and Conditions for Shariah Compliant Account
Operations and Schedule of Fees for the Account available on the ADCB website
www.adcb.com. I agree to provide the Bank with updated contact, passport and
other details relevant to the Account within a reasonable time in the event that
any of the information I have provided ADCB changes.

IOaEG /QGbEG

XHCG H VaCGh bOh M H G

q eG L CH Y Ld Hb Z Ff IQH GH bCG
QOCG EG .k Se dP iCJQG GPEG fc e QOe CG e eG J e CGh ac e dG GH QdG
k ah G H UG hdGh MCG hG G d edG hdGh MCH GdEG Y aGhCGh
QdG XHCG d hdEG bG Y G H UG SdG hLh eSG jdG MC
UJ CGh ,dG RGLh GdH UG fdG MCH dG jhJ Y aGhCG .www.adcb.com
.QdG XHG d eb ee G J M GPG de eR Ia N H U GP iNG
:dG bJ

Customer Signature:

Date

d d - m m-

For Bank Use Only

Membership with:

jQdG

y y y y

TRB

TML

Non-TML

Salary Transfer

Mortgage

a dG GSE

Promo Code
Insurance

Other

New RM Name:

Account Open Request by (Maker) The above customer has signed in my presence.

Ver.01FATCA/June2014

Remarks:
Screening

CBBL

Source Code:

TP

Excellency benefit:

TP

U.S. Indicia Found:

Documents provided:

Source Code:

Date:

Signature

Name:

General Processing Department

Signature

Screening

Travel

Sports

Shopping

Yes*

No

* Please complete W8-BEN or W9 form.

W9

W8-BEN

Account Open Request Verified by (Checker)

Department:

Name:

Privilege Club benefit:

CBBL

WC

Account No. 1

Account No. 2

Account No. 3

Account No. 4

Department:
Date:

Entert.

No

FRM-SDD-012-2.4

New RM Code: