Professional Documents
Culture Documents
APPLICATION TYPE:
New Affiliation
System Upgrade
Change of Ownership
PERSONAL DETAILS
TITLE: { } MR
{ } MRS
{ } MS
NAME: _____________________________________________________________________________
(Last Name)
(First Name)
(Middle Name)
(First Name)
(Middle Name)
(Municipality/Town/Barangay)
___________________________________________________________________________________
(City/Province)
(Zip Code)
GENDER:
MALE
FEMALE
CIVIL STATUS:
SINGLE
MARRIED
WIDOW/WIDOWER LEGALLY SEPARATED
SPOUSE NAME (If Applicable): _________________________________________________________
(Last Name)
(First Name)
(Middle Name)
(MM/DD/YYYY)
CITIZENSHIP: _______________________
PROFESSION OF SPOUSE/COMPANY NAME: ________________________________________________
POSITION: _______________________ SPOUSE CONTACT NUMBER: _________________________
OUTLET/FINANCIAL INFORMATION
BUSINESS NAME: ___________________________________________________________________
BUSINESS TYPE:
SINGLE PROP.
PARTNERSHIP
CORPORATION
COMPLETE BUSINESS ADDRESS: __________________________________________________________
(Room/Floor/Bldg. Name/No./Street)
(Municipality/Town/Barangay)
___________________________________________________________________________________
(City/Province)
(Zip Code)
OFFI
OFFICE TELEPHONE NUMBER: _______________
CURRENT POSITION HELD: ____________________
(First Name)
(Middle Name)
RELATION: _________________
CONTACT NUMBER: _____________________
EMAIL ADDRESS (Pls. indicate your official E-mail address): ____________________________________
AUTHORIZED SIGNATORIES:
1.) ______________________________________________________________________________
(Last Name)
(First Name)
(Middle Name)
2.) ______________________________________________________________________________
(Last Name)
(First Name)
(Middle Name)
DECLARATION
1. I hereby confirm that the foregoing information is true and correct, and that supporting
documents attached hereto are genuine and authentic and voluntarily submitted by me for the
purpose of my application to the Facility.
2. I consent to the companys disclosure of information concerning myself/ourselves or my/our
subscription to financial institutions, or similar organizations.
3. I hereby authorize (UNIFIED PRODUCTS AND SERVICES) to use my personal information for
communication related to my subscription, to any new products and services offered by you or to
any products and services offered by third parties.
4. I hereby authorized (UNIFIED PRODUCTS AND SERVICES) to send me SMS alerts pertaining to your
(UNIFIED PRODUCTS AND SERVICES) promos and services.
5. I am aware of the fees, rates and charges relevant to the Facility availed of.
6. I agree that this Subscription Agreement shall govern our relationship for the service currently
availed of and facility will avail of in the future.
__________________
Merchants Signature
(over printed name)
_____________
Date
RECOMMENDATION/ENDORESMENT
ENDORSED BY (DEALER)
Date Recvd by
In-House
REGCODE NUMBER
ADDRESS:
Account ID:
SPECIAL INSTRUCTIONS/RECOMMENDATIONS:
______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________