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SECURITY BANK MASTERCARD ONLINE FORM

PLEASE FAX TO: 840-2436 / 815-3649 / 812-1272


WHAT CARD ARE YOU APPLYING FOR?
Choose your Security Bank MasterCard Classic Gold Platinum
If we are not able to issue your preferred Card at this time, will you accept a Security Bank Classic MasterCard instead?
Yes No
YOUR PERSONAL INFORMATION
COMPLETE NAME (Last, First, Middle)

NAME TO APPEAR ON CARD (should not exceed 25 characters, nicknames are not allowed)

MOTHER'S FULL MAIDEN NAME (Last, First, Middle)

Gender Male Female Civil Status Single Married Separated Widowed


Citizenship No. of Dependents Date of Birth
Children
Others (yyyy/mm/dd)
Highest Educational Attainment
HS Undergraduate College School _____________________ Degree __________________________
Post-Graduate Vocational
Car Ownership
Personal, monthly amortization P( ) Company-provided Both None
Home ownership Years of Stay in Present Address
Owned Living with Parents Living with Relatives
Mortgaged, monthly amortization P( ) Rented, monthly rental P( )
Home Address (No., Street, Subdivision, Zone, Town/City, Province) Zip Code

Telephone ( ) Mobile ( ) E-mail Address


YOUR SPOUSE'S INFORMATION
COMPLETE NAME (Last, First, Middle)
Date of Birth Gross Annual Income Company/ Business Name
(yyyy/mm/dd)
Telephone ( ) Mobile ( ) E-mail Address
YOUR PREFERRED BILLING ADDRESS
Please deliver Card to: Home Office Please deliver Statement of Account to: Home Office
YOUR BUSINESS AND FINANCIAL INFORMATION
I am: Employed Self-employed No. of Years in Current Work/Business ________ Position ________________________
Nature of Business________________________________________________ SSS/GSIS No.________________________________________________
Total No. of Years Working/ in Business_______________________________ TIN ________________________________________________________
COMPANY/BUSINESS NAME
Company/Business Address (Floor, Building, No., Street, Subdivision, Zone, Town/City, Province) Zip Code

Gross Annual Income Other Sources of Income


Telephone ( ) Fax ( ) E-mail Address
YOUR OTHER CREDIT CARDS/ BANK ACCOUNT INFORMATION
1. Card ______________ Card No. _________________________ Credit Limit ____________________ Member Since (mm/yyyy)
2. Card ______________ Card No. _________________________ Credit Limit ____________________ Member Since (mm/yyyy)
Are you currently a Security Bank Depositor?
Yes Account No. _____________________________ Branch ________________________________
No Other Banks where you currently maintain an account
Name of Bank/ Branch _____________________ Account No. ___________________________
YOUR SUPPLEMENTARY CARD
COMPLETE NAME (Last, First, Middle)

NAME TO APPEAR ON CARD (should not exceed 25 characters, nicknames are not allowed)

Relationship to Primary Cardholder Date of Birth Gender


Male Female
(yyyy/mm/dd)
Home Address (No., Street, Subdivision, Zone, Town/City, Province) Zip Code

Telephone ( ) Mobile ( ) E-mail Address


YOUR PERSONAL REFERENCE
May be any relative, friend and/or trade reference not living with you (officemate not allowed)

PERSONAL REFERENCE (1) PERSONAL REFERENCE (2)


NAME NAME
Relationship Relationship
Home Address Home Address
Office Address Office Address
Home Tel. No. (Landline) Home Tel. No. (Landline)
Office Tel. NO. (Landline) Office Tel. NO. (Landline)
YOUR AFFIRMATION AND AUTHORIZATION
By affixing my signature, I confirm that the information provided above is true and correct. I authorize you to verify and investigate it from whatever sources you may consider appropriate. This
authorization also allows said sources to furnish you information concerning my deposit accounts, placements or credit dealings and any other information that may be requested.

I understand that falsifying any information on enclosed documents is sufficient ground for legal action and for rejection of my application. I understand that should my application be denied, SB
Cards Corporation has no obligation to furnish the reason for such rejection. By signing at the Card when delivered to me, I signify my agreement to the Terms and Conditions accompanying the Card.
Furthermore, I acknowledge that in case of issuance of a Supplementary Card, I hold myself jointly and severally responsible for all obligations, charges and liabilities incurred by my supplementary
cardholders and that, in the event of delinquency, I hereby authorize SB Cards to report and include my/our names in the negative listing of any credit card bureau or institution. I further waive any
defense of minority or illiteracy on any extension Cardholders.

DON'T ________________________________________ ________________________________________________


FORGET Signature of Primary Applicant & Date Signed Signature of Supplementary Applicant & Date Signed

PROGRAM CLASS : AGENT CODE : SOURCE:


CCI-32-11/03

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