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Customer Request Form

Customer Request Form
Name:* CPR No: *
Mobile:*   Home:*
Office:   Fax:
Visa Card:    
Card Number:      
Card Number:    
Card Number:    
Attachment: Yes   No   Card   Payment Slip   Others    
Please select at least one reason
Card Replacement: Card Only   Card & Pin   Lost/Stolen   Magnetic/damaged   Security/Fraud  

Reason:   (Subject to BD 5 fee)
Card Reactivation: Reason:     
Limit Increase: Permanent Increase (attach copy of latest pay slip)    
Temp Increase: Amount Requested:   For:  (Subject to BD 10 fee)  
Limit Decrease: Reason:  Amount Requested:    
Fixed Deposit Release: Reason:    
Card Status Letter:    
Statement Copy:  (Subject to BD 2 fee per copy)    
Frequent Flyer Program: Enrollment      Existing Gulf Air:     
Tele Bank Pin No.:    
This form was submitted to: *    
CrediMax Main Office      
BBK Branch.Please specify the branch:    
Attachments: (Maximum 3 MB)    
I declare that the information stated in this form is true and correct to the best of my knowledge.    
                  Signature:                Date:  

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Fields Marked * are compulsory