Ph lc 01

NGN HNG NNG NGHIP V PHT TRIN NNG THN VIT NAM
VIETNAM BANK FOR AGRICULTURE AND RURAL DEVELOPMENT
GIY NG K THNG TIN KHCH HNG CUSTOMERS APPLICATION INFORMATION

(Dnh cho khch hng l T chc For Corporation )

Phn dnh cho ngn hng
(Bank use only)

Knh gi:

CHI NHNH (BRANCH): .M khch hng: ........

NHNo&PTNT VIT NAM (AGRIBANK VIETNAM)
Customer No

M ti khon:
Account No
Tn giao dch vin:
Tn Ting Vit ( IN HOA)*: ....
Bank teller Name
VietNamese Full Name (CAPITAL)*
M giao dch vin:
Bank teller No
Tn ting Anh( IN HOA)*:
1. Thng tin c bn ca khch hng Base Information

English Full Name (CAPITAL)*

Tn tt*: ............................................................Tn tt(ting Anh) *.

Short Name*

Short Name(English)*

a ch(Address)*:.
S in thoi (Tel No)*:..S Fax(Fax No):..Email:
S quyt nh thnh lp*: ...Ngy cp*: /./..Ni cp*:.
Established decision number*
Issue Date*
Issue By*
S KKD*: Ngy cp*:/./..Ni cp*:
Business licence number*
Issue Date*
Issue By*

M s thu *:
Tax code number*

Ngy cp *:/./..Ni cp*:

Issue Date*
Issue By*

Ngy thnh lp **: ..............Thng kt thc nm Ti chnh: ..........

Incorporation Date**
Fiscal Year End (Month)
2. Thng tin doanh nghip Corporation Information
Loi t chc(Organization Type)*:

Tr s chnh
Headquarters

Vn phng i din

Chi nhnh

RepresentativeOffice

Branch

Loi hnh doanh nghip(Type of Enterprise ) *:

Doanh nghip Nh nc Trung ng Doanh nghip Nh nc a phng
State- Owned Enterprise

Cng ty c phn khc

State-Regional Enterprise

Cng ty TNHH Nh nc

Join stock company

Foreign investment Company

T chc ti chnh
Financial institution

Khc.
Other

Cng ty c phn Nh nc
Join stock company

Cng ty TNHH t nhn Cng ty lin doanh

Limited Company

Doanh nghip c vn u t nc ngoi

Limited Company

Paper Company

Doanh nghip t nhn

Private Enterprise

Hp tc x
Coperative

Khc:..
Other

Tn cng ty m: Nc cng ty m hot ng:.......

Parent Company:
Parent Company Country:
Thng hiu: (Ting Vit)...Thng hiu: (Ting Anh): ........................................
Commercical Name:(Vietnamese)
Commercical Name: (English)

Ngnh ngh kinh doanh chnh *: Sn phm chnh:.......................

Business Line Type*
Major Product:
Qui m doanh nghip (Business Scale Type)*:
Ln Trung bnh Nh

Phm vi kinh doanh (Business Scope)**:

Tnh, thnh ph
Ton quc Quc t

Large

Province/ city

Medium

Small

Nationwide

International

S lao ng hin c*: ............................................S lng chi nhnh*:............................................................

Number of Labors*
Number of Locations*
Nim yt trn TTCK:
C Khng
Registered on Stock market: Yes No

i din:.C quan ch qun:.................................

Representative:
The Organism in charge:

Tng s c phn: .....Gi tr c phiu nm gi (%):......................Thu nhp rng: ..................................

Total Number of Shares:
Holding Percentage (%)
Net Worth:
Doanh s bn hng: .....Tng thu nhp: .......................Tin thu:.......Tng ti sn:...................
Net Sales:
Net Income:
Total Assets:
Doanh s thu chi tin mt
bnh qun/ thng (VND)*

Di 500 triu

T 500 triu 1 t

< 500 Millions

500 Millions 1 Billions

Average cash flow monthly*

T 1 t - 5 t
1- 5 Billions

T 5 t - 10 t
5 10 Billions

Trn 1 t
> 1 Billions

Trn 10 t
> 10 Billions

Vn iu l (Legal Capital)*:Vn t c ca ch s hu (Actual Capital):....................................

3. Ngi lin h - Contact Person
H v tn*:Chc v:.Phng ban:..
Full Name*
Position
Division
S CMND/H chiu* :Ngy cp*:Ni cp*:
ID No / Passport No*
Issued Date*
Issued by*
S in thoi (Tel No)*:..S Fax (Fax No):Email :.
4. Thng tin qun l v c ng (Management and Shareholders)
4.1. Thng tin qun l (Management)**
STT
(Seq)

Chc v
(Position)

H v tn
(Full
name)

Gii
tnh
(Sex)

Ngy sinh
(Birthday)

Quc tch
(Nationaly
)

S CMND
/H chiu
(ID No
/Passport
No)

Ngy
cp
(Issue
Date)

Ni cp
(Issue by)

a ch ni
(Address)

Ch tch HQT
(Chairman of the
Board)
Tng Gim
c/Gim c
(President/Director
)
Ch tch hi ng
thnh vin
Ch tch cng ty
(Chairman of
Company)
Trng ban Kim
sot
(Chief Checker)

4.2. Thng tin c ng (Shareholders)**

Tn c
ng
(Full
name)

a ch ni
/ Tr s
chnh
(Address)

Gii
tnh
(Sex)

Ngy
sinh
(DOB)

Quc tch
(Nationality)

Loi nhn dng

CMND/
H chiu
(ID No/
Passport
No)

S KKD
(Business
licence

M s thu

M nhn dng
(Identification
Code)

(Tax No)

T l
c phn
(Share
%)

No)

4.3. Thng tin v i din gp vn ti php nhn khc (Information about representative of capital
contributed at other legal entity)**
H v tn
(Full Name)

Gii
tnh
(Sex)

Ngy sinh
(Birthday)

Quc tch
(Nationaly
)

S CMND
/H chiu
(ID No
/Passport No)

Ngy
cp
(Issue
d
Date)

Ni cp
(Issued
By)

a ch
ni
(Address)

Chc
danh ti
php nhn
khc
(Poisition
)

Tn cng ty lm i
din
(The name of company
representation)

Chng ti cam kt nhng thng tin trn l ng s tht v tun theo php lut ca Nh nc v qui nh ca
Ngn hng.
We agree that this information is truly, obey the banks rules and regulation as well as the governments law.

5. Mu du v ch k *
Specimen signature anh Stamp*
H tn v chc v
(Name & position)
Ch ti khon (Account holder)
H tn (Full name): ..
Chc v (Position): ..

Ch k th nht
(First signature)

Ch k th hai
(Second signature)

Mu du
(Stamp)

Ngi c y quyn (Authorized person)

H tn (Full name): ..
Chc v (Position): .
Ngi c y quyn (Authorized person)
H tn (Full name): ..
Chc v (Position): .
Ngi c y quyn (Authorized person)
H tn (Full name): ..
Chc v (Position): .
K ton trng (Chief of Accountant)
H tn (Fullname):
Chc v (Position): ...
Ngi c y quyn (Authorized person)
H tn (Full name): ..
Chc v (Position): .
Ngi c y quyn (Authorized person)
H tn (Full name): ..
Chc v (Position): .
Ngi c y quyn (Authorized person)
H tn (Full name): ..
Chc v (Position): .
. , ngy (date). thng (month) .. nm (year)
Th trng n v k tn v ng du
Directors signature and companys stamp

PHN DNH CHO NGN HNG / Bank use only

,ngy (date) . thng (month) . nm (year) ..
Chp thun(Approved by)
Ngy hiu lc: (Date)....
K ton trng
Gim c
(Chief of accountant)
(Director)