Application for Service and Token Registration cash@work

Please fill using block letters and please tick whichever is applicable and please give cross for un-filled section.

The undersigned, 1. Name Title ID Number (Passport or National ID) Address Phone No. Cellphone No.

2.

Name Title ID Number (Passport or National ID) Address Phone No. Cellphone No.

each acting in his capacity as stated above, therefore validly act for and on behalf of (hereinafter referred to as CUSTOMER), hereby apply for Service and Token cash@work Registration, provided by PT Bank Danamon Indonesia, Tbk. (hereinafter referred to as BANK), with following d ata :

COMPANY PROFILE

Companys Name Domicile and Office Address City Postal Code Phone Number Fax Number E-mail Address Contact Person

: : : : : : : : (Filled by Bank) CIF: Corporate ID: Servicing Branch Code: LOB: RO/RM Code

Industry Segmentation Banking Financial Institutions Non Banking Financial Institutions Consumer Goods Industry Property and Construction

: Utility and Infrastructure Agriculture and Mining Automotive Textile and Garment Electronic Trading Chemical Industry Others______

SERVICE PACKAGE Inquiry Basic Premium

REGISTERED ACCOUNT

No

Account Number/ Credit Line

Under the Name of

Types of Deposits/Credit Savings Giro Deposit Loan Debit

Types of Access Credit Inquiry

1. 2. 3. 4. etc.

Notes : 1) Please attach related documents; 2) Please fill according to the type of savings; 3) Only available for inquiry.

TOKEN No 1. 2. 3. 4. User ID User Name . . . . Token Serial No.* . . . . A B C D

Notes : * : filled by Bank for the order of new token A : Order of new token C : Changing User ID B : Replacement for lost/broken card D : Block/Unblock

COSTS Cost of Service package/monthly Cost of Token Bank account number that will be debited for monthly fee :

STATEMENT AND POWER OF ATTORNEY By signing this form, CUSTOMER stated the followings : 1. TOKEN RECIPIENT assigned by CUSTOMER are : a. Name Title ID Number (Passport or National ID) Address Phone No. Cellphone No. b. Name Title ID Number (Passport or National ID) Address Phone No. Cellphone No. : : : : : : : : : : : :

2.

Authorized the registered user of User ID to execute Financial and Non-Financial Transaction with cash@work Service.

3.

All information and data stated in this form are true, complete and valid as well as basis for CUSTOMERs participation in cash@work Service.

4.

Unless stated differently in this form, terms used in this form have the same meaning and definitions as stated in General Terms and Conditions of cash@work Service.

5.

CUSTOMER has read and agree to abide by the General Terms and Conditions of cash@work Service mentioned behind this form as an integral and inseparable part. [Place, Date/Month/Year] CUSTOMER TOKEN RECIPIENT

stamp duty

(signature and name)

(signature and name)

(signature and name)

(signature and name)

Verification and Application (filled by Bank) Account and Signature Verified (by Branch) Account Checked Signature Verified Application Approved by Official

Name & Signature Processed

Date Name & Signature Date Name & Signature Corporate ID and Account Registered (by CMD Implementation) Checked Approved

Date

Name & Signature

Date

Name & Signature

Date

Name & Signature

Date

Parameter Application (filled by Bank) Inputted and processed by Parameter Div./Common File

Name & Signature

Date

Name & Signature

Date

PROOF OF RECEIPT TOKEN RECIPIENT hereby stated : 1. Have received materials/instruments in forms of User ID and Token stated in Service and Token cas@work application form; 2. 3. Have received the above mentioned instruments in good and complete condition; Have full responsibilities on the execution and the use of the above mentioned instruments.

RECIPIENT (TOKEN RECIPIENT)

(signature and name)

(signature and name)

THE SURRENDER (BANK)

(signature and name)

(signature and name)