Forms Preview — Industra – A Bank That Understands Businesspeople

Customer information

1

Name of the Company *

Registration No. *

Resident

Non-resident

Current account of the Company *

Name of the Company on the card *

Name and Surname of the Cardholder on the card *

Address of residence of the Cardholder (street, building, apart. No., city, country, postcode) *

Phone number *

E-mail *

Password (will be used for identification of the Cardholder) (alphabetical and / or numerical combination) *

Information on the payment card and account currency

2

Payment Card type: *

MasterCard Business

Currency of the Card account: *

EUR

USD

Printing of currency type on a payment card: *

With printing¹

Without printing

Preferred credit, amount in words, numbers *

Based on the assessment of the credit collateral oered by the Client and/or solvency of the Client, the Bank will take decision on granting credit limit and issuance of the Card.

The Bank has the right to refuse to issue credit Card and to grant credit limit to the Client, and maintains its rights not to provide information on reasons for refusal.

¹ for additional fee

Information about financial collateral

3

To befilled in for the selected type of collateral

Funds on the current account

Funds on the term - deposit account

Account No.

In case of granting a credit, the funds, deposited on the current/term - deposit account in the (Amount / Currency)

should be regarded as collateral for securing my liabilities and the said funds should be blocked till full coverage of my liabilities, in accordance with the Terms and Conditions for Issuing and Servicing of the Bank Payment Card.

Guarantee

Pledge

Guarantee contract No.

concluded between the Bank and the Guarantor

Guarantor’s account No.

Confirmation

5

By signing this I, do hereby acknowledge, that

I confirm that I have read the General Business terms and conditions of AS "Industra Bank", Price-list of services, fully understand them and agree to observe the requirements;

I am aware of the fact that the Bank shall be obligated to provide information to the Credit Register of the Bank of Latvia and shall be entitled to receive information from the Credit Register of the Bank of Latvia, in the events prescribed by its regulations (www.bank.lv);

I confirm the completeness and accuracy of the information provided in this application, and undertake to notify the Bank on any changes related to the information indicated in this application.

To be signed by Cardholder

Please open the payment card account with the Bank and issue the payment Card

Cardholder’s Name, Surname

(Signature)

(Date)

Name, Surname of the authorized person of the Company