TO BE FILLED-UP BY THE COURIER

DATE :
COURIER :
CH :
REF. NO. :

AUTHORIZATION FORM

______________
DATE

Dear Valued Cardholder,

You may assign an authorized representative to receive the card on your behalf in case you will not be
around to receive the card upon delivery. Kindly accomplish the Authorization Form. The authorized
representative shall (1) submit to our personnel your duly accomplished Authorization Form; and (2)
present your ID, as well as said authorized representative’s ID, as specified below.

BPI FAMILY SAVINGS BANK

I authorize my representative whose name and signature appear below to receive my BPI FAMILY
CREDIT CARD on my behalf. I am leaving with my authorized representative our unexpired IDs, as
follows (please tick appropriate box):

Cardmember’s ID Representative’s ID

o Passport o Passport
o Driver’s License o Driver’s License
o PRC (Professional Regulation o PRC (Professional Regulation
Comm.) ID Comm.) ID
o Employment ID (w/ signature and o Employment ID (w/ signature and
photo) photo)
o Membership Card (w/ signature) o Membership Card (w/ signature)
o ATM / Credit Card o ATM / Credit Card

I am aware that BPI Family Savings Bank highly recommends that I personally receive my card as a
safety measure. In this regard, I will hold free and harmless, as well as indemnify BPI Family Savings
Bank, its board of directors, stockholders, officers and employees, successors-in-interest and assigns,
from any actions, claims, damages and/or charges arising from the use of my BPI Family Credit Card by
any party on account of said card being received through my authorized representative as indicated
below:

__________________________ ___________________________
Printed Name of Cardholder Printed Name of Representative

______________________ _______________________
Signature of Cardholder Signature of Representative

By signing above, (1) I further certify that any information given by me in connection with the application
for and issuance of BPI Family Credit Card is true and correct and that any material misrepresentation or
falsity therein shall be construed as an act to defraud BPI Family Savings Bank (BPIFB) for which civil
and/or criminal liability can be pursued against me.; (2) I authorize BPIFB to verify and investigate any
information I have provided to BPIFB from whatever sources BPIFB may consider appropriate; (3) I also
1
certify that I have read and understood, and agree to be bound by the terms and conditions governing
the issuance and use of the card, including all future amendments thereto, which I have read from the BPI
Website; (4) I accept liability for all charges to the principal card and extension cards; and (5) I
understand and acknowledge that using the card also signifies my agreement to be bound by the BPI
Family Credit Card Terms and Conditions, including all future amendments thereto.

1ONLINE AUTHORIZATION FORM

Terms and Conditions
http://www.bpicards.com/Page/61