PNB ESSENTIALS MASTERCARD

APPLICATION FORM

Benefits:

3 FREE annual fee for the first three (3) years Fraud Transaction Insurance (by enrollment)

FREE lifetime annual fee for supplementary cards Earn points at P50 = 1 point.
Redeem points for cash credits, miles,
FREE Travel Insurance of up to P3 Million and other rewards.

0% interest installment for your purchases and

FREE Purchase Protection Insurance of up to P250K
other installment programs. KATE DE LA CRUZ

Terms and Conditions apply

1. PERSONAL INFORMATION (BSP-REQUIRED)

First Name Middle Name Last Name

dfhh
Date of Birth Place of Birth Sex Education Mother’s Full Maiden Name No. of dependents TIN/SSS/GSIS/UMID
mm dd yyyy Male High School College
Female Some College Graduate School

Present Residence Address (Unit #, Bldg./ House #, Street, Barangay/District) Nationality / Country of Citizenship Status
Filipino Non-Filipino Single Separated
(state country of citizenship) Married Widow

(Province/Region, Country) ZIP Code Years of Stay Home Landline Number Mobile Number

Is permanent residence address same as present residence address?

Yes No (please provide permanent residence address below)
Present Residence Address (Unit #, Bldg./ House #, Street, Barangay/District)
EMAIL ADDRESS

ELECTRONIC STATEMENT OF ACCOUNT

(Province/Region, Country) ZIP Code Your monthly Statement of Account (SOA) will be delivered in
electronic form and will be sent via your registered email address.

Go green with Electronic Statement of Account (eSOA) and view

your monthly Statement through your email anytime and anywhere.
Home Ownership If you wish to receive your statement via paper billing, please check
the “paper billing” option below and we will deliver your statement
Owned Rented P ____________________ Others ___________________________ to your card delivery address. Paper Billing

Living with Relatives Mortgaged P ____________________

If you are a foreign national, you must submit the following:

1. ACR / ICR or I-Card 2. Philippine Retirement Authority ID And ANY of the following (check submitted I.D. / document)
I.D. No. ____________________
Passport with ACR Internal Revenue Service I.D. (IRS I.D.) SSS I.D.
Expiry ____________________
National I.D. Work Permit Issued by DOLE (Mandatory if employed in the Philippines)

2. NATURE OF WORK / SELF-EMPLOYMENT / BUSINESS (BSP-REQUIRED) 3. SOURCE OF FUNDS/INCOME (BSP-REQUIRED)

Employed Self-employed / Practicing Profession You may check more than one:
Nature of Work / Profession / Business (Based on SEC / DTI / Business Permit)
Private Salary Ave. Monthly Amount:
Public Business Revenue Ave. Monthly Amount:
Commission Ave. Monthly Amount:
Name of Employer / Business Position / Rank No. of years in the firm
Professional Fees Ave. Monthly Amount:
Pension Ave. Monthly Amount:

Employer / Business Address (Unit #, Bldg / House #, Street, Others (Please specify): Type and amount:
Barangay / District, City, Province / Region, Country) ZIP Code Employer Contact Number Remittance Remitter Name:
Relationship with Applicant:
Country Origin of Remittance:
Previous Employer Position/Rank No. of years with
Savings/ Deposit /
previous employer Investments Ave. Daily Balance:
Current relationship with PNB
Account Number: ___________________________ PNB Branch: ___________________

4. SPOUSE INFORMATION
First Name Middle Name Last Name Date of Birth Nationality / Country of Citizenship
mm dd yyyy Filipino Non-Filipino
(state country of citizenship)

Business/Company Address (Number, Street, District, City/Province) Office Tel. No. Employment Status Mobile Number

Employed Self-Employed Unemployed

5. MABUHAY MILES MEMBERSHIP 6. AUTOMATIC DEBIT ARRANGEMENT (ADA)

Provide your Mabuhay Miles number in order to enjoy the conversion of earned rewards point to Mabuhay Miles. If Automatic Debit Arrangement (ADA) from your PNB Checking or Savings Account. If you
you do not have a Mabuhay Miles Account yet, you may get one by enrolling online at www.mabuhaymiles.com want to pay via ADA from your PNB CASA, please fill out below:

Please indicate your existing Mabuhay Miles membership number: Auto Debit my PNB Peso acct. # ________________________________________
Full Minimum
7. CARD DELIVERY INFORMATION Auto Debit my PNB Dollar acct. # _______________________________________
Full Minimum
Choose where you want your card to be delivered: Home Office

8. DECLARATION
By signing below, I/we are applying for a PNB Credit Card. I/We agree to abide by and be governed by the Terms and Conditions governing the issuance and use of the PNB Credit Card and all future amendments thereto. I/We authorize
Philippine National Bank (PNB) to verify the information in this application and to receive and exchange information about me/us, including requesting reports from PNB's consumer credit reporting or reference or other accredited bureaus.
I/We hereby acknowledge and authorize: 1) the regular submission and disclosure of my basic credit data (as defined under R.A. 9510 and its Implementing Rules and Regulations) to the Credit Information Corporation (CIC) as well as any
updates or corrections thereof; and 2) the sharing of my basic credit data with other lenders authorized by the CIC, and credit reporting agencies duly accredited by the CIC. I/We also authorize PNB and their affiliates to contact these
sources for information at any time, to use information about me/us, including information from this application and from consumer credit reports, for marketing and administrative purposes and to share such information with each other.

By signing up for this product and/or service, I/we authorize PNB, their branches, subsidiaries, affiliates, representatives, and their authorized third party service providers to collect, use, and disclose my/our personal data and share such
data for marketing and promotional purposes such as, but not limited to, calls, emails, and/or SMS. I/We may withdraw such consent at anytime by calling the PNB Cards Customer Service or sending a notification via mail or email to PNB.

I/We hereby agree to waive my/our right/s regarding the confidentiality of deposits under R.A. 1405, as amended, as the disclosure is necessary and relevant in the evaluation of my/our application for a PNB Credit Card and to ensure a
successful debit under an auto-debit payment arrangement with my/our PNB account should I/we decide to avail of the auto-debit payment facility to my/our PNB Credit Card. I/We hereby authorize the bank, in the event that my
account becomes past due, to offset against my deposit, any unpaid balances or endorse my account to an accredited third party agency, and subsequently cancel my card. I/We further authorize and consent to the Philippine National
Bank to be the recipient of these information and to conduct random verification with the BIR in order to establish authenticity of the Income Tax Return (ITR).

I/We hold ourselves, jointly and severally liable for all obligations and liabilities arising from the use of the PNB Credit Card and supplementary card/s and, in the the event that my/our application for a PNB Credit Card is disapproved, the
Philippine National Bank is under no obligation to provide me/us with the reason for such a decision.

The accomplished application form and requirement/s submitted will become the property of the Philippine National Bank. The Philippine National Bank is under no obligation to return the said documents.

All PNB Credit Cards are issued for personal use only. Should PNB find that my/our transactions are relatively higher than the usual personal consumption, PNB has the right to cancel or revoke the credit card immediately.

Further hereby declare, that in compliance with BSP Circular No. 472, I agree to send a copy of my latest duly-stamped ITR or BIR Form 2316; or latest 3 months payslips, if employed; or Audited Financial Statements, if self-employed.

FOR BANK USE ONLY

 Signature of Principal Applicant Date

Source Code:

Solicitor’s Name:
BDC Employee No:

Branch/Channel Code:

PNB is regulated by the Bangko Sentral ng Pilipinas. BSP contact details: (+632) 708 7087 / consumeraffairs@bsp.gov.ph OPAF_ESSMC-BR_MAY 2018