DATE OF BOOKING:

CUSTOMER INFORMATION SHEET

CUSTOMER'S INFORMATION

ACCOUNT NAME: ILDEFONSO JR SABINO PASCUAL

 BIRTHDATE:

 HOME TELEPHONE NUMBER:

 MOBILE NUMBER:
 EMAIL ADDRESS:
 HOME ADDRESS BLOCK / LOT NUMBER:
 HOME STREET & BRGY.:
 HOME MUNICIPALITY/ PROVINCE/ CITY/ ZIP CODE:

 EMPLOYER/ BUSINESS NAME:

 OFFICE/ BUSINESS TELEPHONE NUMBER:
 OFFICE/ BUSINESS MOBILE NUMBER:
 OFFICE/ BUSINESS EMAIL ADDRESS:
 OFFICE/ BUSINESS BUILDING NAME:
 OFFICE/ BUSINESS STREET & BRGY.:
 OFF/ BUS MUNICIPALITY/PROVINCE/CITY/ZIP CODE:

 SPOUSE NAME:
 SPOUSE TELEPHONE NUMBER:
 SPOUSE MOBILE NUMBER:
 SPOUSE EMAIL ADDRESS:
 SPOUSE ADDRESS:

 CONTACT PERSON (relative):

 RELATION:
 CONTACT NUMBER:
 EMAIL ADDRESS:

 CONTACT PERSON (not a relative):

 RELATION:
 CONTACT NUMBER:
 EMAIL ADDRESS:

I hereby certify that all information stated above are correct to the best of my knowledge.

ILDEFONSO JR SABINO PASCUAL

SIGNATURE OVER PRINTED NAME DATE
(Please affix only your handwritten signature in this form.)
FOR BANK'S USE ONLY

FIAC XPAC CODE REQUIREMENTS: REQUIREMENTS ARE VALIDATED BY:

FICR XPAC CODE _____Promissory Note
EXPIRATION DATE _____EIR Form
BUCKET(QUALIFIER) _____2 Valid IDs CONTACT INFORMATION VALIDATED BY:
CURRENT BUCKET _____Supporting Documents (as applicable)
CYCLE _____PDCs (as applicable)
Issuing Bank
Branch
Check Numbers

ENDORSED BY: CHECKED BY: APPROVED BY: DEVIATION APPROVED BY

COLLECTIONS OFFICER/ STAFF SRP ADMIN OFFICER/ STAFF COLLECTIONS SENIOR MANAGER COLLECTIONS DIVISION HEAD

DEVIATION:
_____Y
_____N
REASON:

Please send back the signed documents through fax # __________________ or through email __________________________________________
Please attach the following:
2 Valid IDs
Latest One-Month Payslip/ Latest ITR /
COE with Compensation