Debit Card Authorization Form printable pdf download

Citibank ATM/Visa Debit Card Authorization Form

Gentlemen:

I hereby name, constitute and appoint Mr. / Ms. ________________________________, the primary custodian and

Mr. / Ms. ________________________, the back-up custodian designated by the Company in the Company

Designation Memo, to be my duly authorized representative to receive my Citibank ATM/Visa Debit Card, for me and

in my name, place and stead. I am presenting a copy of my valid and unexpired identification document for your

verification.

______Passport ______Driver’s License _______SSS ID _______NBI Clearance _______ Postal ID

______Voter’s ID _____Company ID

_______Voters ID _______Police Clearance ______ACR

______Others Specify: ______________

I hereby grant the above named representative full power and authority to do and perform all acts as may be

required or necessary for the above transactions as fully to all intents and purposes as I might or could do if

personally present, and I ratify and confirm all that my said representative shall lawfully do or cause to be done by

virtue of this Authorization. I hereby release and hold Citibank N.A. free and harmless from any liability of whatsoever

kind and nature arising from the misuse of the Citibank ATM/Visa Debit Card by any party (ies) on account of the

receipt of the Citibank ATM/Visa Debit Card by the representative hereinabove indicated.

___________________________________

_____________________________

Signature over printed name of Cardholder

Date

PIN Authorization Form

Gentlemen:

I hereby name, constitute and appoint Mr. / Ms. ________________________________, the primary custodian and

Mr. / Ms. ________________________, the back-up custodian designated by the Company in the Company

Designation Memo, to be my duly authorized representative to receive my Citibank PIN, for me and in my name,

place and stead. I am presenting a copy of my valid and unexpired identification document for your verification.

______Passport ______Driver’s License _______SSS ID _______NBI Clearance _______ Postal ID

______Voter’s ID _____Company ID

_______Voters ID _______Police Clearance ______ACR

______Others Specify: ______________

I hereby grant the above named representative full power and authority to do and perform all acts as may be

required or necessary for the above transactions as fully to all intents and purposes as I might or could do if

personally present, and I ratify and confirm all that my said representative shall lawfully do or cause to be done by

virtue of this Authorization. I hereby release and hold Citibank Savings free and harmless from any liability of

whatsoever kind and nature arising from the misuse of the Citibank PIN by any party (ies) on account of the receipt of

the Citibank PIN by the representative hereinabove indicated.

___________________________________

_____________________________

Signature over printed name of Cardholder

Date

Debit Card Authorization Form