Online Account Opening Please enable JavaScript in your browser to complete this form.Date/TimeDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CIF Noຜູ້ຖືບັນຊີຮ່ວມ Joint account holderAccount 1ຝາກປະຫຍັດ Savingກະແສລາຍວັນ Currentຝາກປະຈໍາ Term DepositCurrencyLAKUSDTHBAccount 1 amountAccount 2ຝາກປະຫຍັດ Savingກະແສລາຍວັນ Currentຝາກປະຈໍາ Term DepositCurrencyLAKUSDTHBAccount 2 amountAccount 3ຝາກປະຫຍັດ Savingກະແສລາຍວັນ Currentຝາກປະຈໍາ Term DepositCurrencyLAKUSDTHBAccount 3 amountຂໍ້ມູນລູກຄ້າ/Personal informationຊື່/Name and Surname (in Lao) *ຊື່/Name and Surname (in English) *ວັນ, ເດືອນ, ປີເກີດ/Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ເພດ/Gender *ຊາຍ/Maleຍິງ/Femaleສັນຊາດ/Nationality *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islandsປະເທດທີ່ເກີດ/County of birth *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islandsເລກບັດປະຈຳຕົວ ID/Passport/FB book No.ລົງວັນທີ/Date of IssueDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ວັນໝົດອາຍຸ/Date of ExpiryDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ສະຖານະພາບ/Marital Status *SingleMarriedOthersຂໍ້ມູນການຕິດຕໍ່/Contact Informationເຮືອນເລກທີ/House No: *ບ້ານ/Village *ເມືອງ/District *ແຂວງ/Province *Attapeu ProvinceBokeo ProvinceBolikhamxai ProvinceChampasak ProvinceHouaphanh ProvinceKhammouane ProvinceLuang Namtha ProvinceLuang Prabang ProvinceOudomxay ProvincePhongsaly ProvinceSalavan ProvinceSavannakhet ProvinceVientiane ProvinceVientiane CapitalSainyabuli ProvinceSekong ProvinceXaisomboun ProvinceXiangkhouang Provinceປະເທດ/Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islandsມືຖື/Mobile Number *Emailປະເພດທີ່ຢູ່ອາໄສ/Residence Type *ຂອງຕົວເອງ / Ownedເຊົ່າ Rentedອາໄສຢູ່ກັບພໍ່ແມ່ / Living with Parentsອື່ນໆ / Othersປະເພດບັນຊີ ແລະ ຈໍານວນເງິນຝາກເບື້ອງຕົ້ນ Type of account and Initial Deposit Amount *ເງິນຝາກປະຢັດ Saving Acctເພື່ອທຶນການສຶກສາ Save for ChildrenMerchantເງິນຝາກກະແສລາຍວັນ Current Acctເງິນຝາກປະຈໍາ Term Depositຈຳນວນເດືອນຂອງເງິນຝາກປະຈຳ/Term monthsCurrencyLAKUSDTHBAmountຮັບດອກເບ້ຍເມື່ອຄົບກໍານົດ/Interest receivable on maturityຮັບດອກເບ້ຍລາຍເດືອນ/Monthly Interestປິດບັນຊີເມື່ອຄົບກໍານົດ/Close on Maturityຝາກຕໍ່ຕົ້ນທຶນ ແລະ ດອກເບ້ຍ/Auto rollover on principal and interestຝາກຕໍ່ຕົ້ນທຶນເທົ່ານັ້ນ/Auto rollover on principal onlyອັດຕາດອກເບ້ຍ/Interest rateDate / TimeDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date / TimeDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ໂອນຈາກບັນຊີ/Pay inໂອນໄປບັນຊີ/Pay outຜະລິດຕະພັນການບໍລິການເພີ່ມເຕີມ / Additional Product *ເປີດນຳໃຊ້ບັດ ATMເປີດນຳໃຊ້ແອັບ MJ Saduakເປີດນໍາໃຊ້ E-Bankingບໍ່ຕ້ອງການ / No requirementອື່ນໆ / Othersການນຳໃຊ້ບັນຊີ Account Operationຈຸດປະສົງໃນການເປິດ ແລະ ນຳໃຊ້ບັນຊີຂອງທ່ານ? The purpose of opening an account with MJBL?ເພື່ອຮັບເງິນ/ຈ່າຍເດືອນ pay/receive salaryນຳໃຊ້ເຂົ້າໃນການເຄື່ອນທຸລະກິດ for business activitiesສະສົມເງິນ savingອື່ນໆ otherກະລຸນາລະບຸ (please specify)ການຄາດຄະເນຈຳນວນທຸລະກຳທີ່ຄາດວ່າຈະເຮັດຕໍ່ເດືອນ the estimate number of transaction per month ຄັ້ງ/ເດືອນ Times/monthການຄາດຄະເນຈຳນວນເງິນຈະເຄື່ອນໄຫວເຮັດຕໍ່ເດືອນ the estimate number of transaction per month ກີບ/ເດືອນ Kip/monthອາຊີບ ແລະ ລາຍຮັບ Professional information and incomeHave you ever been a political exposed person (PEP) or a relative or closed associate of PEP in the past and present? ທ່ານເຄີຍເປັນບຸກຄົນທີ່ມີສະຖານະພາບທາງການເມືອງ ຫຼື ບຸກຄົນທີ່ກ່ຽວຂ້ອງກັບ ບຸກຄົນທີ່ມີສະຖານະພາບທາງການເມືອງບໍ່?ແມ່ນ Yesບໍ່ແມ່ນ Noພະນັກງານ/Employedພະນັກງານ / Employedທຸລະກິດສ່ວນຕົວ / Self-employedວ່າງງານ / Unemployedອາຊີບອິດສະຫຼະ / Freelanceອື່ນໆ / Others (Place Specify)ຕຳແໜ່ງ/Job Title *ບ່ອນປະຈຳການ/Name of Business/Companyທີ່ຢູ່ບໍລິສັດ/ company addressລາຍຮັບຕໍ່ເດືອນ/Total Monthly Income Level *LAK 2,000,000LAK 2,000,000 - LAK 5,000,000LAK 5,000,000 - LAK 10,000,000LAK 10,000,000 - LAK 15,000,000LAK 15,000,000 - LAK 20,000,000LAK 20,000,000 - LAK 30,000,000LAK 30,000,000 - LAK 50,000,000LAK 50,000,000ເງື່ອນໄຂໃນການສັ່ງຈ່າຍ ແລະ ເຄື່ອນໄຫວບັນຊີ / Mandate: Please (√) atA ໝາຍເຖິງເຈົ້າຂອງບັນຊີ ມີສິດຢ່າງເຕັມສ່ວນພຽງຜູ້ດຽວໃນການສັ່ງຈ່າຍ, ປ່ຽນແປງ, ຍົກເລີກ, ປິດບັນຊີ, ຂໍເພີ່ມ ຫຼື ລົບລ້າງລາຍເຊັນໃນບັນຊີ /A means the sole proprietor of the account to payment, change, cancel, close the account, additions or deletions to the signature in the account.ລາຍເຊັນດຽວໃຊ້ໄດ້, ໝາຍເຖິງ A, B ມີສິດຢ່າງເຕັມສ່ວນເທົ່າທຽມກັນ ໃນການສັ່ງຈ່າຍ, ປ່ຽນແປງ, ຍົກເລີກ, ປິດບັນຊີ, ຂໍເພີ່ມ ຫຼື ລົບລ້າງລາຍເຊັນໃນບັນຊີ /Anyone to sign, meaning that A, B are fully equal rights to payment, change, cancel, close the account, additions or deletions to the signature in the account.ເຊັນຮ່ວມກັນ A ໃນ B ຈຶ່ງມີສິດໃນການສັ່ງຈ່າຍ, ປ່ຽນແປງ, ຍົກເລີກ, ປິດບັນຊີ, ຂໍເພີ່ມ ຫຼື ລົບລ້າງລາຍເຊັນໃນບັນຊີ /Anyone authorized signatories in eligible for payment, change, cancel, close the account, additions or deletions to the signature in the account.ເຊັນຮ່ວມກັນທັງໝົດ, ໝາຍເຖິງ A, B ຕ້ອງໄດ້ມີການເຊັນຮ່ວມກັນທັງໝົດ ຈຶ່ງມີສິດໃນການສັ່ງຈ່າຍ, ປ່ຽນແປງ, ຍົກເລີກ, ປິດບັນຊີ, ຂໍເພີ່ມ ຫຼື ລົບລ້າງລາຍເຊັນໃນບັນຊີ /All to sign, that means A, B must have all signatures to eligible for payment, change, cancel, close the account, additions or deletions to the signature in the account.ກໍານົດເງື່ອນໄຂດ້ວຍຕົນເອງ /Please specify other conditionsຂ້າພະເຈົ້າ/ພວກຂ້າພະເຈົ້າ ຂໍຢັ້ງຢືນວ່າໄດ້ອ່ານ ແລະ ເຂົ້າໃຈເອກະສານກ່ຽວກັບທຸກຂໍ້ກໍານົດ ແລະ ເງື່ອນໄຂໃນການເຄື່ອນໄຫວບັນຊີທີ່ທະນາຄານຂອງທ່ານໄດ້ວາງອອກ/ This is to certify that I (We) have read and understood well on your account term and condition document.ຂ້າພະເຈົ້າ/ພວກຂ້າພະເຈົ້າ ຂໍຢັ້ງຢືນວ່າໄດ້ສະໜອງຂໍ້ມູນໃສ່ໃນຟອມການເພີ່ມທະວີຄວາມເອົາໃຈໃສ່ລູກຄ້າ/ແບບຟອມການຊອກຮູ້ລູກຄ້າ ໃຫ້ກັບທະນາຄານທ່ານແລ້ວ /This is to certify that I (We) have read and understood well on your Customer Due Diligence Form (CDD)/ Customer Risk Profile Form Know Your Customer (KYC).ຂ້າພະເຈົ້າ/ພວກຂ້າພະເຈົ້າ ຂໍຢັ້ງຢືນວ່າໄດ້ສະໜອງຂໍ້ມູນໃສ່ໃນແບບຟອມແຈ້ງສະຖານະທີ່ເປັນບຸກຄົນອາເມຣິກາ/ບໍ່ເປັນບຸກຄົນອາເມຣິກາໃຫ້ກັບທະນາຄານທ່ານແລ້ວ /This is to certify that I (We) have read and understood well on your Form for Self-Certification of status of Customer as U.S. Person or Non-U.S. Person (Fatca).ກໍານົດເງື່ອນໄຂດ້ວຍຕົນເອງ /Please specify other conditionsແຈ້ງສະຖານະທີ່ເປັນບຸກຄົນອາເມລິກາ/ບໍ່ເປັນບຸກຄົນອາເມລິກາ Self-Certification of status of Customer as U.S. Person or Non-U.S. Person (FATCA)ພາກທີ 1/ Part 1: ສະຖານະລູກຄ້າ/Status of Customer1. ຖ້າທ່ານຕອບ “ແມ່ນ” ໃນຂໍ້ໃດຂໍ້ໜຶ່ງ ກະລຸນາປະກອບແບບຟອມ W-9 /If you check “yes” in the box, please complete form W-9.1.1 ທ່ານແມ່ນພົນລະເມືອງອາເມລິກາບໍ? Are you a U.S. citizen?ແມ່ນ/Yes ບໍ່ແມ່ນ/No1.2 ທ່ານແມ່ນຜູ້ຖືບັດປະຈໍາຕົວຜູ້ມີທີ່ຢູ່ຖາວອນຢ່າງຖືກຕ້ອງຕາມກົດໝາຍໃນອາເມລິກາ (ຕົວຢ່າງ:ບັດຂຽວ)? Are you a holder of U.S permanent Resident Card (e.g. Green Card)?ແມ່ນ/Yes ບໍ່ແມ່ນ/No1.3 ທ່ານມີຖານະເປັນຜູ້ທີ່ມີພູມລໍາເນົາໃນສະຫະລັດອາເມລິກາເພື່ອວັດຖຸປະສົງໃນການເກັບພາສີອາກອນຂອງສະຫະລັດອາເມລິກາແມ່ນຫຼືບໍ່? Are you a U.S Resident for U.S tax purposes?ແມ່ນ/Yes ບໍ່ແມ່ນ/Noຖ້າທ່ານປະກອບແບບຟອມ W-9 ໃນຂໍ້ 1 ກະລຸນາ ຂ້າມ ຄຳຖາມ ຂໍ້ 2 ຢູ່ທາງລຸ່ມ / If you completed form W-9 in item 1, please skip the questionnaire in item 2 as below.2. ຖ້າທ່ານຕອບວ່າ “ແມ່ນ” ໃນຂໍ້ໃດຂໍ້ໜຶ່ງ ກະລຸນາປະກອບແບບຟອມ W-8BEN ພ້ອມທັງໃຫ້ເອກະສານປະກອບ ສໍາເນົາບັດປະຈໍາຕົວສໍາລັບຄົນລາວ ຫຼື ສໍາເນົາໜັງສືເດີນທາງສໍາລັບຄົນຕ່າງຊາດທີ່ບໍ່ແມ່ນຄົນອາເມລິກາ If you check “Yes” in any one box, please complete IRS form W-8BEN and provide a copy of Lao Citizen ID card or A copy of passport in case you are not a Lao Citizen which indicate that you are not a U.S person2.1 ທ່ານເກີດໃນສະຫະລັດອາເມລິກາ ຫຼື ດິນແດນທີ່ເປັນຂອງສະຫະລັດອາເມລິກາ ແຕ່ໄດ້ສະຫຼະຄວາມເປັນພົນລະເມືອງອາເມລິກາຢ່າງສົມບູນຕາມກົດໝາຍແມ່ນຫຼືບໍ່? Where you born in the U.S or U.S Territory but have legally surrendered U.S Citizenship? If “Yes” please provide a copy of Certificate of loss of Nationality of the U.S.ແມ່ນ/Yes ບໍ່ແມ່ນ/No2.2 ທ່ານມີທີ່ຢູ່ອາໄສໃນປະຈຸບັນ ຫຼື ຢູ່ເພື່ອການຕິດຕໍ່ໃນສະຫະລັດອາເມລິກາສໍາລັບບັນຊີທີ່ເປີດໄວ້ ກັບ/ຜ່ານຜູ້ຮັບແມ່ນ ຫຼືບໍ່? Do you have a current U.S residence address or U.S mailing address for the account opened with/or through the Receiver?ແມ່ນ/Yes ບໍ່ແມ່ນ/No2.3 ທ່ານມີເບີໂທລະສັບໃນສະຫະລັດອາເມລິກາເພື່ອການຕິດຕໍ່ທ່ານ ຫຼື ບຸກຄົນອື່ນທີ່ກ່ຽວຂ້ອງກັບບັນຊີທີ່ເປີດໄວ້ ກັບ/ຜ່ານ/ຫຼືມີຢູ່ກັບ ຜູ້ຮັບແມ່ນ ຫຼື ບໍ່? Do you have U.S telephone number for contacting you or another person in relation to the account opened with or through or maintained with Receiver?ແມ່ນ/Yes ບໍ່ແມ່ນ/No2.4 ທ່ານມີຄໍາສັ່ງເຮັດລາຍການໂອນເງິນເປັນປະຈໍາໂດຍອັດຕະໂນມັດຈາກບັນຊີທີ່ເປີດໄວ້ ກັບ/ຜ່ານ/ຫຼືມີຢູ່ກັບ ຜູ້ຮັບໄປຍັງບັນຊີໃນສະຫະລັດອາເມລິກາແມ່ນ ຫຼື ບໍ່? Do you have standing instructions to transfer funds from the account opened with or through or held with the Receiver to an account maintained in the U.S.?ແມ່ນ/Yes ບໍ່ແມ່ນ/No2.5 ທ່ານໄດ້ຮັບອໍານາດ ຫຼື ໃຫ້ອໍານາດການລົງລາຍເຊັນແກ່ບຸກຄົນທີ່ມີທີ່ຢູ່ໃນສະຫະລັດອາເມລິກາ ທີ່ກ່ຽວຂ້ອງກັບບັນຊີເປີດໄວ້ ກັບ/ຜ່ານ/ຫຼືມີຢູ່ກັບ ຜູ້ຮັບແມ່ນ ຫຼື ບໍ່? Do you have a power of attorney or signatory authority for the account opened with or through or held with the Receiver granted to person with U.S. address?ແມ່ນ/Yes ບໍ່ແມ່ນ/Noພາກທີ 2/Part 2: ການຢືນຢັນ ແລະ ການປຽ່ນແປງສະຖານະ Confirmation and change of Status1. ທ່ານຢືນຢັນວ່າຂໍ້ມູນທີ່ທ່ານໃຫ້ໃນແບບຟອມນີ້ເປັນຄວາມຈິງ, ຖືກຕ້ອງ ແລະ ຄົບຖ້ວນສົມບູນ     You confirm that the information provided by you in this form is true, correct, accurate and complete. 2. ທ່ານຮັບຮູ້ແລະຕົກລົງວ່າຖ້າທ່ານມີສະຖານະເປັນບຸກຄົນອາເມລິກາແຕ່ຂໍ້ມູນທີ່ໃຫ້ຕາມແບບຟອມນີ້ຫຼືຕາມແບບຟອມ W-9 ເປັນຂໍ້ມູນທີ່ບໍ່ຖືກຕ້ອງຫຼືບໍ່ຄົບຖ້ວນສົມບູນທະນາຄານມີສິດ ໃຊ້ດຸນພິນິດແຕ່ພຽງຝ່າຍດຽວທີ່ຈະຢຸດຕິຄວາມ     ສໍາພັນທາງການເງິນ/ທາງທຸລະກິດກັບທ່ານ ບໍ່ວ່າທັງໝົດຫຼືບາງສ່ວນຕາມທະນາຄານເຫັນສົມຄວນ.     You acknowledge and agree that if you are a U.S. person but the information provided on this form or Form W-9 is false, incorrect, incomplete, the bank shall be entitled     to terminate, at its sole discretion, the entire banking/business relationship with you or part of such relationship as the bank may deem appropriate. 3. ທ່ານຕົກລົງທີ່ຈະແຈ້ງໃຫ້ທະນາຄານຊາບແລະນໍາສົ່ງເອກະສານປະກອບໃຫ້ແກ່ທະນາຄານພາຍໃນ 30ວັນ ຫລັງຈາກມີເຫດການປ່ຽນແປງທີ່ເຮັດໃຫ້ຂໍ້ມູນຂອງທ່ານທີ່ລະບຸໄວ້ແບບຟອມນີ້ບໍ່ຖືກຕ້ອງ.     You agree to notify and provide relevant documents to the bank within 30days after any change in circumstance that causes the information provided in this form to be     incorrect. 4. ທ່ານຮັບຮູ້ແລະຕົກລົງວ່າໃນກໍລະນີທີ່ທ່ານບໍ່ໄດ້ດໍາເນີນການຕາມຂໍ້3 ຂ້າງຕົ້ນຫຼືມີການນໍາສົ່ງຂໍ້ມູນປອມ ບໍ່ຖືກຕ້ອງ ຫຼືບໍ່ຄົບຖ້ວນຍ້ອນສົມບູນກ່ຽວກັບສະຖານະຂອງທ່ານ ທະນາຄານ ມີສິດໃຊ້ດຸນພິນິດແຕ່ພຽງຝ່າຍດຽວທີ່ຈະຢຸດຕິຄວາມ     ສໍາພັນທາງການເງິນ/ທາງທຸລະກິດກັບທ່ານບໍ່ວ່າທັງໝົດຫຼືບາງສ່ວນຕາມທະນາຄານເຫັນສົມຄວນ.     You acknowledge and agree that failure to comply with item3 above or provision of any false incorrect, incomplete information as to your status, shall entitle the bank     to terminate at its sole discretion, the entire banking/business relationship or part of such relationship as the bank may deem appropriate.ພາກທີ 3/Part 3: ການຍິນຍອມໃຫ້ເປີດເຜີຍຂໍ້ມູນ ແລະ ການຫັກບັນຊີ (Authorization for information disclosure and account withholding) ທ່ານຕົກລງໃຫ້ຄວາມຍິນຍອມທີ່ບໍ່ສາມາດຍົກເລີກເພີກຖອນແກ່ທະນາຄານໃນການດໍາເນີນການດັ່ງຕໍ່ໄປນີ້ You hereby irrevocably authorize the bank to:1. ເປີດເຜີຍຂໍ້ມູນຕ່າງໆຂອງທ່ານໃຫ້ແກ່ໜ່ວຍງານຈັດເກັບພາສີອາກອນໃນປະເທດ ແລະ/ຫຼື ຕ່າງປະເທດເຊີ່ງລວມເຖີງໜ່ວຍງານຈັດເກັບພາສີອາກອນຂອງສະຫະລັດອາເມລິກາ (Internal Revenue Service : IRS) ຂໍ້ມູນດັ່ງກ່າວ     ລວມເຖີງຊື່ລູກຄ້າ ທີ່ຢູ່ ເລກປະຈໍາໂຕຜູ້ເສຍພາສີ ໝາຍເລກບັນຊີ ສະຖານະຕາມຫຼັກເກນເລື່ອງ FATCA (ຄື: ເປັນຜູ້ ປະຕິບັດຕາມ ຫຼື ຜູ້ບໍ່ໃຫ້ການຮ່ວມມື) ຈໍານວນເງິນ ຫຼື ມູນຄ່າຄົງເຫຼືອໃນບັນຊີ ການຈ່າຍເງິນເຂົ້າ-ອອກຈາກບັນຊີ     ລາຍການເຄື່ອນໄຫວທາງບັນຊີ ຈໍານວນເງິນ ປະເພດມູນຄ່າ ຂອງຜະລິດຕະພັນທາງການເງິນ ແລະ/ຫຼື ຊັບສິນອື່ນໆ ທີ່ມີຢູ່ກັບທະນາຄານຕະຫອດຈົນຈໍານວນລາຍໄດ້ ແລະ ຂໍ້ມູນອື່ນໆທີ່ກ່ຽວກັບຄວາມສໍາພັນທາງການເງິນ/ທາງທຸລະກິດທີ່     ອາດຖືກຮ້ອງຂໍໂດຍໜ່ວຍງານທາງພາສີອາກອນໃນປະເທດ ແລະ/ຫຼື ຕ່າງປະເທດເຊີ່ງລວມເຖີງ IRS ດ້ວຍ     Disclose to domestic and/or foreign tax authorities, including the U.S Internal Revenue Service (IRS), your name, address, taxpayer identification number, account     number, FATCA compliance status (i.e., compliant or recalcitrant), account balance or value, the payments made into or from the account, account statements,     the amount of money, the type and value of financial products and/or other assets held with the bank, as well as the amount of revenue and income and any information     regarding the banking/business relationship which may be requested or required by domestic and/ or foreign tax authorities, including IRS ; and 2. ຫັກເງິນຈາກບັນຊີຂອງທ່ານ ແລະ/ຫຼື ເງິນໃດທີ່ທ່ານໄດ້ຮັບຈາກຫຼືຜ່ານທະນາຄານໃນຈໍານວນທີ່ກໍາຫນົດໂດຍໜ່ວຍງານຈັດເກັບພາສີອາກອນໃນປະເທດ ແລະ/ຫຼື ຕ່າງປະເທດເຊິ່ງລວມເຖີງ IRS ພາຍໃຕ້ບັງຄັບຂອງກົດໝາຍ ແລະ/ຫຼື ກົດເກນ     ຕ່າງໆລວມເຖີງຂໍ້ຕົກລົງໃດໆ ລະຫວ່າງທະນາຄານກັບໜ່ວຍງານຈັດເກັບພາສີອາກອນດັ່ງກ່າວ     Withhold from your account and/or the income derived from or though the bank in the amount as required by domestic and/or foreign tax authorities, including the IRS,     pursuant to the laws and/or regulations, and any agreements between the bank and such tax authorities, ຖ້າທ່ານບໍ່ໃຫ້ຂໍ້ມູນທີ່ຈໍາເປັນຕໍ່ການພິຈາລະນາເປັນບຸກຄົນອາເມລິກາ ຫຼື ຂໍ້ມູນທີ່ຈໍາເປັນຕ້ອງລາຍງານໃຫ້ແກ່ທະນາຄານ ຫຼື ບໍ່ສາມາດຈະຂໍໃຫ້ຍົກເວັ້ນການບັງຄັບໃຊ້ກົດໝາຍທີ່ຫ້າມ ການລາຍງານຂໍ້ມູນໄດ້ທະນາຄານມີສິດ ດຸນພິນິດແຕ່ພຽງຝ່າຍດຽວທີ່ຈະຢຸດຕິຄວາມສໍາພັນທາງການເງິນ/ທາງທຸລະກິດກັບທ່ານບໍ່ວ່າທັງໝົດຫຼືບາງສ່ວນຕາມທີ່ທະນາຄານເຫັນສົມຄວນ If you fail to provide the information required to determine whether you are a U.S person, or to provide the information required to be reported to the bank, or if you fail to provide a waiver of a law that would prevent reporting, the bank shall be entitled to terminate, at its sole discretion, the entire banking/business relationship with you or part of such relationship as the bank may deem appropriate. ຂ້າພະເຈົ້າຮັບຮູ້ ແລະ ຕົກລົງປະຕິບັດຕາມຂໍ້ກໍານົດແລະເງື່ອນໄຂຕ່າງໆ ໃນເອກະສານສະບັບນີ້ເຊີ່ງລວມເຖີງຕົກລົງຍິນຍອມໃຫ້ມີການເປີດເຜີຍຂໍ້ມູນການຫັກບັນຊີແລະການຢຸດຕິ ຄວາມສໍາພັນທາງການເງີນ/ທາງທຸລະກິດກັບຂ້າພະເຈົ້າເພື່ອເປັນຫຼັກຖານສໍາຄັນແຫ່ງການນີ້ຈື່ງໄດ້ລົງລາຍເຊັນໄວ້ຂ້າງເທິງ By signing the account opening form, I hereby acknowledge and agree to the terms and conditions specified herein, which include permitting the disclosure of information, account withholding and termination of banking/business relationship.Submit