UniCredit iriac Bank SA

CERERE EMITERE CARD DEBIT - persoane juridice

UniCredit Tiriac Bank SA, company administered in a two-tier system, located in Romania, Bucharest, Bulevardul
Expozitiei nr. 1F, 1st District, registered with the Trade Register under number J40/7706/1991, with the Banking Register
under number RB-PJR-40-011/18.02.1999 and registerred with ANSPDCP notification number 10964, Sole Registration
Code 361536, Fiscal Attribute RO, subscribed and paid-up share capital RON 379.075.291,20.

Issuance Debit Card Request - Legal Entities

Data / Date

Sucursala / Branch

1. Detalii Client / Client details

Denumire titular cont / Account holder name

Telefon / Phone number

Numar fax / Fax number

Adresa e-mail / E-mail address

Adresa sediu social / Registered office address
Nr. Registrul Comertului / Trade Register No.
Cod postal/Postal code

CIF / FIC

Tara / Country

Judet / County

Solicitam UniCredit Tiriac Bank SA sa emita card(uri) de plata cu informatiile furnizate in aceasta cerere/
We ask UniCredit Tiriac Bank SA to issue payment card(s) considering the information delivered in this request
Denumire pachet / Package name

Pachet / Package
Da / Yes

Nu / No

MasterCard

Card principal / Main card

Card suplimentar / Additional card

Card principal / Main card

Card suplimentar / Additional card

Gold Business
VISA
Electron Business
Electron Business co-brand Metro
Silver Business
Gold Business

UniCredit Tiriac Bank S.A., societate administrata in sistem dualist, cu sediul in Romania, Bucuresti, Bulevardul
Expozitiei nr. 1F, sector 1, inregistrata in Registrul Comertului sub nr. J40/7706/1991, in Registrul Bancar sub nr. RBPJR-40-011/18.02.1999 si inregistrata la ANSPDCP cu notificarea nr. 10964, cod unic de inregistrare 361536,
atribut fiscal RO, capital social subscris si varsat 379.075.291,20 RON.

Date personale utilizator / User personal data

Prenume si nume / Name and surname
Locul si data nasterii / Place and date of birth

Sex

Denumire companie / Companys name *

Numele mamei inainte de casatorie / Mothers name before marriage

F
M
Act identitate (serie si numar) / Identity card (series and number)

CNP / NIF

Adresa/Address: Strada / Street

Nr. / No.

/ PIN / FIC
Bl.

Sc. / En.

Cetatenie /Citizenship
Ap. / App.

Localitate / City

Judet / County

Numar telefon / Phone number

Telefon serviciu / Business phone no.

Persoana de contact / Contact person

Telefon persoana de contact/Contact person

phone no.

Primul cont de comisioane debitat / First

commissions account to be debited

Primul cont debitat/First account to be debited

Al doilea cont debitat/Second account to be

debited

Al doilea cont de comisioane debitat /

Second commissions account to be debited

Date personale utilizator card suplimentar / Personal data of the additional user

Sex

Prenume si nume / Name and surname

Locul si data nasterii / Place and date of birth

Denumire companie / Companys name *

Numele mamei inainte de casatorie / Mothers name before marriage

F
M
Act identitate (serie si numar) / Identity card (series and number)

CNP / NIF

Adresa/Address: Strada / Street

Nr. / No.

Judet / County

Numar telefon / Phone number

/ PIN / FIC
Bl.

Sc. / En.

Cetatenie /Citizenship
Ap. / App.

Localitate / City

Telefon serviciu / Business phone no.

* se va prelua pe card in limita a 25 de caractere/as it will appear on the card, in maximum 25 characters

bB03_156 - 05/20130601

Pagina / Page 1/ 2

Date personale utilizator card suplimentar / Personal data of the additional user
Persoana de contact / Contact person

Telefon persoana de contact/Contact person

phone no.

Primul cont de comisioane debitat / First

commissions account to be debited

Primul cont debitat/First account to be debited

Al doilea cont debitat/Second account to be

debited

Al doilea cont de comisioane debitat /

Second commissions account to be debited

Varianta in limba romana va prevala.

The Romanian version shall prevail.

Client
Nume, semnatura si stampila reprezentant
legal/Name, signature and stamp of the
client's legal representative

Stampila/Stamp

Nume si semnatura utilizator/i / User(s)s name and signature

UniCredit iriac Bank S.A.

Nume, pozitie si semnatura reprezentant
bancar/ Name, position and signature of
bank representative

Nume, pozitie si semnatura reprezentant

bancar/ Name, position and signature of
bank representative

Stampila/Stamp

Se va completa de catre UniCredit iriac Bank SA / It will be completed by UniCredit iriac Bank SA
Numar card(uri) /Card(s) number

bB03_156 - 05/20130601

Carduri aprobate de (nume si semnatura) /

Approved by (name and signature)

Pagina / Page 2/ 2