Prepaid Cards

Giver’s Information
Title
*First name		*Family name
*Father’s name		Mother’s full maiden name
*E-mail		Education
Place of birth		Date of birth
Register number		Nationality
Register Place		Gender
Education		Marital status
Spouse’s full maiden name		No. of children
Age of children		No. of dependants (if any)
Recipient’s Information
Title
First name		Family name
Father’s name		Mother’s full maiden name
E-mail		Education
Place of birth		Date of birth
Tel		Gender

Home Address
Bldg. name		Floor no.
Street		City
*Tel		Mobile
Apartment is

Employment
Status
Company / employer name		Company / employer phone no.
Time spent at company (in years)		Employer’s Bank(s) / Branch(es)
PREPAID CARD
Type of card
Personalized Card
Amount to be set on the card (min USD 25):
I would like the monthly statements to be sent to:
Funding Method
Payment method:
For Credit Cards only
Card to be debited
Issued by:		Card No:
Exp. date:		Amount: USD
Sequence
For Automatic Transfer letters only
Fransabank clients
Branch name:		Account No:
Amount: USD
Sequence
Non-Fransabank clients:
Letter of authorization to be filled and signed at Fransabank branch
How did you know about this card:

Giver’s Information