Credit Card Application Form

CREDIT CARD APPLICATION FORM

CARDHOLDER INFORMATION

Name

Name to Appear on Card

(Last Name, First Name, Middle Name)

(Maximum of 21 Characters)

Birthdate

Place of Birth

Citizenship

Gender

Civil Status

(MM/DD/YYYY)

Mother’s Maiden Name

SSS No.

TIN

Number of Dependents

Current Address

Zip Code

(Bldg., Street No., Street, Subd, City)

Permanent Address

(Bldg., Street No., Street, Subd, City)

Home Phone

Home Ownership

Years/Months of Stay

Do you own a car?

Educational Attainment

[ ] Owned

________________

[ ] No

(Not Mortgaged)

[ ] High School

Mobile Phone

[ ] Owned

[ ] Yes

How many? _______

(Mortgaged)

[ ] College

[ ] Living with Parents/Relatives

[ ] Mortgaged

[ ] Some College

[ ] Rented

[ ] Not Mortgaged

Email Address

[ ] Post Graduate

SPOUSE INFORMATION

Name

Birthdate

(Last Name, First Name, Middle Name)

(MM/DD/YYYY)

Employer’s Name

Position

Years/Months with Firm

Office Phone

Office Address

Zip Code

WORK AND FINANCES

Employer’s Name

Unit/Dept./Branch

Position

Years/Months with Firm

Office Phone

Email Address

Office Address

Zip Code

Gross Annual Income

Other Income

Other Source of Income

C redit Cards

Bank Accounts

Issuer

Card Number

Credit Limit

Date Issued

Bank Name

Type of Account

SUPPLEMENTARY CARDS

(Should be 14 Years Old & Above)

Name

Name

(Last Name, First Name, Middle Name)

(Last Name, First Name, Middle Name)

Name to Appear on Card

Name to Appear on Card

(Maximum of 21 Characters)

(Maximum of 21 Characters)

Birthdate

Relationship to Cardholder

Birthdate

Relationship to Cardholder

(MM/DD/YYYY)

(MM/DD/YYYY)

Spend Limits

Spend Limits

Signature

Signature

RELATIVE NOT LIVING WITH YOU

Name (Last Name, First Name, Middle Name)

Relationship

Permanent Address

Home Phone

Mobile Phone

MODE OF PAYMENT

Peso

[ ] Pay to Bank

[ ] Auto Debit my Equicom Savings Bank Acct No. ____________________________

[ ] Full Amount

[ ] Minimum Amount Due

Dollar

[ ] Pay to Bank

[ ] Auto Debit my Equicom Savings Bank Acct No. ____________________________

[ ] Full Amount

[ ] Minimum Amount Due

BILLING ADDRESS

Card and Monthly Statements will be delivered:

[ ] Home

[ ] Office

UNDERTAKING

By signing this Equicom Savings Bank Visa Credit Card application form, I/We certify that I/We have read, understood and agree to abide by and be governed by the terms and conditions governing the issuance and use of the Equicom Savings

Bank Credit Card and all future amendments thereto. I/We warrant that all information given in this application form is true and correct.

I/We hold ourselves jointly and severally liable for all obligations and liabilities incurred with the use of the Equicom Savings Bank Credit Card and extension cards and, in the event my/our application for an Equicom Savings Bank Credit Card is

disapproved, Equicom Savings Bank is under no obligation to provide me/us with the reason for such a decision.

Applicant’s Signature

Date

FOR PAYMENT SERVICES DIVISION USE ONLY

Notes:

[ ] Approved

[ ] VISA Gold

Peso Limit

________________

[ ] Reject

Reason _______

[ ] VISA Classic

Dollar Limit

________________

Processed by:

Approved by:

Date