you or c 00s1ng PLDT

PLO 3A REV 02/22

FOR RESIDENTIAL USE ONLY

CAF No: HB 0000001

Start your journey with us and experience the strongest connections at home.

Full Name ( First Name, Middle Name, Last Name}

ELMON MATUGUINAS RENTASIDA

Mother's Maiden Name ( First Name, Middle Name, Last Name}

EULALIA MATUGUINAS RENTASIDA

Birthday (MM/DD/YYYY} Type of ID ID Number

04/06/1981 Driver's License C1521200149

Gender Civi I Status Citizenship

Q
✔ Male Q
✓ Female Q
✔ Single Q
✔ Married Q
✓ Widowed Q
✓ Others Q
✔ Filipino Q
✓ Others

Home Ownership
Q
✓ Living with Relatives/Parents Q
✓ Owned, Mortgaged Q
✓ Owned, Not Mortgaged Q
✓ Rented (Landlord} Q
✔ Rented (Tenant}

Home/I nsta I lation Address Unit/House No. Street/Barangay City

7 5 LOTE ST MEXICO

Province Postal Code Nearest Landmark

PAMPANGA FLYING V GASOLINE STATION

Work and Financial Information

Employment Status Total Household Monthly Income
Q
✔ Student Q
✔ Unemployed without Income 0
✔ 300,001 - above 0
✔ 100,001 - 183,999 0
✓ 29,000 - 38,999

0
✓ Self Employed Q
✔ Employed (Same Firm} More than 2 years
0
✓ 200,001 - 300,000
0
✓ 68,000 - 100,000
0
✓ 18,000 - 28,999

Q
✓ Unemployed with Income Q
✓ Employed (Same Firm} Less than 2 years 0
✓ 184,000 - 200,000 0
✔ 39,000 - 67,999 0
✓ 17,999 - below

Occupation Position / Rank/ Level

SECRET Q
✓ Rank and File Q
✔ Supervisory Q
✓ Managerial Q
✓ AVP and above

Employer's/ Business Name Office Telephone Number

To be Determined

Employer's/ Business Address Unit/Bldg. No. Street/Barangay City

Province Postal Code Nearest Landmark

Mobile Number Home Number Email Address

09957660903 [email protected]

In case we can't reach you, who can we contact? (Full Name, Relationship, contact Number}
JENELYNN MUSNGI BULACSAO SPOUSE 09129644499

0
✔ By providing the information above, I certify that I have secured the permission of my secondary contact person to receive calls for installation activities, bill reminder, service repairs on my behalf_
Should there be an update in my secondary contact person details, I can visit PLOT website (https//mypldthome com) or call 171 hotline

How would you like to receive your Bill? . Would you like us to publish your Name and Number?
Bill Delivery Agreement
YOUR ACCOUNT WILL BE AU TOMATICALLY ENROLLED IN PAPERLESS BILLING AT THE EMAIL
0
✓ YES
I authorize PLOT to pub I ish my name, address and telephone
ADDRESS YOU PROVIDED. number in the Directory Listing (White Pages) I warrant that the
I acknowledge that PLOT shall send me my Bill five (5) calendar days after the Bill Date vla electronic mail (email) information I provided for publishing is accurate and up-to-date,
through the email address I specified in this form_ PLOT is deemed to have validly sent the Bill, and the Bill shall and may be used to reach or access me.
be deemed received at the email address I provided PLOT I agree to hold PLOT free and harmless from any
llabllity for my failure to receive the BilJ despite ft being sent to my email address_
By agreeing to receive my B111 via email, I understand that I will no longer receive a printed copy of my blll_
Should I opt to receive a printed copy of my bill, I will course my request through any of the following channels:
PLOT Hotline by dialing 171, PLDTHome Facebook account by choosing the 'talk to an agent' option, PLDTCares
0
✔ NO
I do not allow PLOT to publish my name, address and telephone
Twitter account or my.Home self-care options_
number in the Directory listing (White Pages)

Voice (Landline/Telephone} Service: Data (Broadband/Internet} Service Lock-in Period: Value Added Services

Q Voice only: 24 months

Device/Content Name MSF Lock-in Period Warranty
Data (Broadband/Internet} Service: Q
✔ FIBR Plans: 36 months
Fiber Unli Plan 1299
Q Wireless Services: 24 months
Speed:
25 Mbps
Volume Allowance:
UNLIMITED
Q
✔ Others:

Modem Fee+ Installation Fee Promo, if applicable:

@) For PLDT Home

Account No. Agent Code Telephone No. Solicited By/Date SO No./SRN No. Clarity ID Encoded By/Date

Rechel Cepriano Rechel Cepriano

P8908902 C18214936
11/21/2022 7:43 pm 11/21/2022 7:43 pm

I hereby certify that all information given here had been verified true and correct.

Rechel Cepriano

PLOT Rep/Sales Agent /Signature aver printed name)

CUSTOMER APPLICATION FORM

■ ■
front PLOT 13 X 8.5
ADUANCE
CUSTOMER'S NAME FORM NAME PLO 3A CUSTOMER APPLICATION FORM SIZE

COMPUTER. FDR.MS, INC .

RFL CODE 23381 PLOT PL03A MCAG R6 PRINTING COLOR Black Red
APPROVED BY: NOTE: THIS COLOR PROOF IS A DESKTOP PRINTOUT. A DEGREE OF DEVIATION IN THE COLORS PRESENTED HEREIN IS EXPECTED IN THE ACTUAL
□ REVISION PRODUCTION RUN DUE TO DIFFERENCES IN CHEMICAL COMPOSITION AND PROPERTIES OF THE SUBSTRATE AND INKS OF THE PRINTING
PROCESS. UPON APPROVAL, THE COMPANY SHALL NOT BE HELD LIABLE FOR ANY GRAMMATICAL, TEXTUAL, SPELLING, TYPOGRAPHICAL
DATE:
SIGNATURE OVER PRINTED NAME
□ APPROVED FOR PRINTING AND OTHER ERRORS FOUND DURING PRE AND POST PRODUCTION. OTHER ERRORS SHALL INCLUDE: PIXELATED IMAGES,
LOW-RESOLUTION IMAGES WRONG PAGINATION, AND ERRONEOUS LAYOUTING, AMONG OTHERS. THE COMPANY SHALL ON A BEST
EFFORTS BASIS ENDEAVOR TO INFORM THE CLIENT OF AND CORRECT ALL SUCH ERRORS IN THE COURSE OF THE PRODUCTION PROCESS.
Numbering we presented on the layout is just a visual representation of Numbering position, actual numbering font style, size and spacing might vary subject to availability of the depth.
 SUBSCRIBER DECLARATION b. The continuous improvement of the Service
(Consumer-Retail Individual)
PLDT may collect, use, process, and analyze how I use the Service in order to understand my needs and
My signature below signifies that: preferences. PLDT's analysis may include maintaining a record of the products and services that I avail (such as
1. All information that I have stated in this application, including all supporting documents that I have submitted, are true the volume and frequency of my use of its voice and data services). PLDT also analyzes other activities such as
and correct. I have voluntarily provided this information and supporting documents to PLDT to facilitate the processing when I participate in PLDT's market research initiatives, when I visit and transact in PLDT stores, and when I visit
and evaluation of this application for Service Subscription (the "Service"). and use any of PLDT websites and mobile apps.
2. I acknowledge that PLOT will require the validation of my identity and my credit history in order to evaluate my I understand that PLDT does so to serve me better, improve the Service for my benefit, and to gain a better
application for the Service. I therefore authorize the following: insight of the kinds of offers that would be relevant to my preferences.
a. For PLDT to obtain relevant information about myself and my credit information from my declared employer or c. The management of the security of its business operations
business, and from the banks, credit card companies, and other financial institutions and service providers with
whom I have existing accounts, as evidenced by the supporting documents I have submitted together with my PLDT may process my personal data to conduct IT security operations, to manage its assets, to ensure my fair use
application; and of its products and services, and for business continuity, disaster recovery, and audit purposes.
b. For PLOT to obtain from my declared employer or business. and for the banks, credit card companies, and other 11. I consent to PLDT's processing of my personal data as I avail of its products and services so that PLDT may be able to
financial institutions and service providers, which I have identified and authorized to release, my information as create and offer better products and services for me, including through direct marketing. I understand that PLDT carries
may be necessary for the evaluation of my application, and for PLOT to verify relevant information concerning out the following processing activities based on my consent.
myself or my subscription with them_ a. Send me offers, recommendations and promotions
3. As an alternative to submitting financial documents together with my application, I acknowledge that I have an option to PLDT processes my usage profile to send me customized offers and promotions through my contact details using
allow PLDT to share ALL of the following personal data with TransUnion Information Solutions, Inc. ("TU"), a private channels such as SMS, voice calls, e-mail, and messaging apps such as but not limited to Viber. This includes
credit bureau operating in the Philippines, to compute for my credit score: location-based offers that are exclusively available in areas that I may frequent.
• Complete Name • Phone number and type
• Address • Gender b. Elaborate my usage profile
• ID number and ID Type {driver's license, passport, company ID, etc.) • Civil Status PLDT may obtain personal information about me from third-party sources such as its subsidiaries, affiliates, and
• Date of Birth business partners, to whom I have also given my consent for them to share my information. I acknowledge that
PLDT creates this enhanced usage profile about me solely to get a deeper understanding of my preferences so
When I choose this option, I acknowledge that: that I may receive even better targeted product recommendations, special offers, and promotions.
a. Generating my credit score by TU does not guarantee that my application will be approved, nor will it foreclose the
possibility of PLDT requiring the submission of financial documents and/or any advanced cash out such as when I I acknowledge that I can choose to object to and withdraw my consent from any of these processes at any time
have a low credit score; by visiting my.pldthome.com, where I am enabled to adjust my privacy settings.
b. TU has the sole control of the algorithm it uses to generate my credit score; and 12. I acknowledge that there are additional ways that PLDT may process my personal data. I understand that these
c. My credit score shall be used by PLDT solely to evaluate my application for the Service. activities are completely optional, and that PLDT will only proceed with the performance of these activities if I give my
In order for TU to provide quality credit score reports and scores to its members by enriching its database, I also consent.
acknowledge that I have the option to allow PLDT to share the following personal data and account data to TU on a a. Create a personal profile about me
monthly basis, as part of PLDT's contribution as a member of TU's private Credit Bureau: PLDT further analyzes my usage profile (such as information about the websites and apps that I may visit when
Personal Data using PLDT's services) to get a deeper understanding of my personal needs and interests. PLDT creates this
• Full Name {first name and last name) • Phone number and type personal profile about me to send me more targeted and personalized product recommendations, special offers,
• ID number and ID Type {driver's license, passport, company ID, etc.) {business or residential) and promotions.
• Address and address type {business or residential) • Gender
• Date of Birth • Civil Status b. Send me offers, recommendations, and promotions from third parties
Account Data PLDT processes my usage information, personal profile information, and contact details to send me customized
• Account number • Outstanding balance offers and promotions from the following third parties:
• Account status {Active, Redirected, Temporary Disconnected, etc.) • Interest and fees {if applicable)
• Account activation date • Number of days past due {if applicable) i. PLDT's sister companies and affiliates. A complete list of these companies may be accessed through
• Latest payment amount • Total amount overdue {if applicable) www.pldthome.com/privacy-policy-partners; and
• Credit limit amount ii. Third-party business partners of PLDT for the promotion of their products and services.

c. Share my usage and personal profile with third parties

I understand that the personal data sharing to TU is done by PLDT with both parties acting as a personal
PLDT may also share my usage and personal profile information with the same sister companies, affiliates, and
information controller. Hence, the personal data disclosed by PLDT to TU will be governed by TU's Terms and
business partners so that they may be able to serve me better and provide me with products and services that are
Conditions and Privacy Policy (and not that of PLDT's) to the extent that the processing is solely under the control
relevant to my needs and interests.
of TU. For more information, I may refer to www.transunion.ph, or contact [email protected] in case I
have questions or concerns regarding TU's personal data processing purposes and activities and my rights as data Should I consent to any of these additional activities, I acknowledge that I can also freely object to and withdraw
subject in relation there to. my consent from any of these activities at any time by visiting my.pldthome.com.
4. I acknowledge that PLDT may temporarily park my service application in cases when: 13. I acknowledge that PLDT will keep all information pertaining to my account, including all personal data about myself,
a. My referred service is currently unavailable. I understand that I may choose to wait up to a maximum of 30 days for as long as I continue to use PLDT's products and services, and for a maximum of ten (10) years after termination.
for my preferred service to become available. If, after the prescribed 30 days, my preferred service is still
unavailable, my service application shall automatically be cancelled, unless I update my application and avail a In the event that my application is not approved by PLDT, I acknowledge that I have the option to ask for the return of
different service type; any information and documents I have provided. Should I fail to exercise my option within the retention period, PLDT
b. PLDT requires additional supporting documents to be submitted. I understand that my service application shall not shall securely delete my personal information.
be processed until these supporting documents are submitted by me. If I am unable to submit these additional 14. I acknowledge that I am afforded certain rights in relation to my personal data under the Data Privacy Act of
documents within 30 days, my service application shall automatically be cancelled; and 2012(Republic Act No. 10173), and that I am entitled (in the circumstances and under the conditions, and subject to
c. I have unpaid balances due to PLDT. I understand that my service application shall not be processed until I have the exceptions, set out in applicable law) to:
settled all unpaid balances. If I am unable to settle payment for these unpaid balances within 30 days, my service a. Request access to the personal data that PLOT processes about me.
application shall be automatically cancelled. b. Request a rectification of my personal data.
I acknowledge that PLDT may contact me for updates or reminders within 30 days that my service application is c. Request the erasure of my personal data.
temporarily parked. I also acknowledge that PLDT may use my parked service application for another three (3) d. Request the restriction of the processing of my personal data.
months after, solely for PLDT to plan future growth, increase its areas of serviceability, and improve its installation e. Request portabillty of my personal data.
services.
When the processing of my personal data is based on my consent, I acknowledge that I have the right to withdraw such
5. When I authorized PLDT to publish my Name, Address, and Telephone Number in the Directory Listing (White Pages) by consent at any time by contacting PLDT's Home Data Privacy Officer, or by accessing my.pldthome.com. I understand that
indicating my preference for publishing in my Service application, I understand that no warranties are agreed upon the this will not affect the lawfulness of the processing that was carried out before I withdrew my consent or PLDT's right to
information published in the case that I will be reached and accessed by any person or number. continue parts of the processing based on legal basis other than my consent. If PLDT is unable to provide me with another
6. I agree to complete my personal profile on the welcome emall that PLOT will send me once my service has been legal basis justifying the processing of my personal data, PLDT will stop the processing and delete my personal data.
activated_ I understand that I need to accompllsh and submit it within thirty (30) days upon receipt of the email.
Otherwise, my service may be subjected to early restriction or barring. I acknowledge that I may learn more about my privacy rights by visiting www.pldthome.com/privacypolicy.
7. I acknowledge that PLDT shall send my Statement of Account ("SOA") for the Service three (3) calendar days after the
Statement Date via electronic mail, through the email address I specified in the application. I agree to hold PLDT free and If I believe that my data privacy rights have been violated, I may get in touch with PLDT's Data Privacy Officer through the
harmless from any liability for my failure to receive the SOA despite it being sent sent to the designated email address. contact details provided below. In some instances, I understand that PLDT may request for supporting documents or proof
I understand that I will no longer received a printed copy of my SOA unless I have stated otherwise by indicated my before it effects any requested changes to my personal data.
preference for SOA delivery in my application.
8. I acknowledge that there are some Instances where PLOT may be required to dlsclose my personal data as part of 'its PLDT Inc.
regular business operations and for the provision of its products and services. I understand that my personal data may PLDT Home Data Privacy Office
be disclosed to:
a. PLDT's service providers, contractors, and professional advisers who help PLDT provide its product and services.
Ramon Cojuangco Building, Makati Avenue, Makati City 1200 Philippines
This includes partner companies, organization, or agencies, and their sub-contractors. For example: PLDT's couriers [email protected]
for bill delivery and customer contact centers providing pre- and post-sales hotline operations;
b. PLDT's subsidiaries and affiliates with whom I have also signed-up with. I understand that this is done only for the
improvement of their respective business and operations. For example: PLDT may share information related to my
use of its products and services with its subsidiaries and affiliates so that they can create new offers that bundle **Acknowledgement and Consent**
their products and services into a single subscription for my benefit; and
c. Other companies to whom I may have also given consent for PLDT to share my information with. For example,
when I sign-up for products and services offered by other companies, they may request for information from PLDT 0
✔ I have read and understood this Subscriber Declaration, and the purposes for which my personal data shall be
processed.
in order for them to validate my identity.
I acknowledge that a compete list of these third parties may be accessed through www.pldthome.com/privacy-
policy-partners. 0
✔
I consent to the disclosure of my Personal Data to TransUnion Information Solutions, Inc. for purposes of computing
my Credit Score. (OPTIONAL)
9. I acknowledge that PLDT processes and discloses my personal dat based on its legitimate interests to function
effectively as a business, and that this is only done when such legitimate interest cannot be overridden by my
fundamental rights or freedom. Such interests, include, among others:
0
✔ I also consent to the monthly disclosure of my Personal Data and Account Data to TransUnion Information
Solutions, Inc. as part of PLDT’s contribution as a Bureau Member. (OPTIONAL)
a. Assisting public authorities by generating, for instance, statistical insights based on my usage of PLDT network and
facilities, for public planning for healthcare, disaster management, and other similar initiatives; and
b. Complying with relevant laws and regulations and other lawful orders and processes.
0
✔ I consent to PLDT’s further analysis of my usage information to create a more personal profile about my needs and
interests. (OPTIONAL)

0
10. I acknowledge that PLDT shall process my personal data based on its legitimate interests to function effectively as a I consent to the disclosure of my usage and personal profile to PLDT’s sister companies, affiliates, and business
business, and that this is only done when such legitimate interests cannot be overridden by my fundamental rights or ✔ partners. (OPTIONAL)
freedoms. Such Interests, include, among others:

a. The continuous improvement of PLDT's business and operations 0

✔
I consent to receive offers, recommendations, and promotions through direct marketing channels from PLDT’s sister
companies and affiliates. (OPTIONAL)
PLDT analyzes my use of its network and services to help in managing my account, provide customer care
activities, investigate and resolve service-related requests and concerns I may have, monitor the quality and
security of its network, train its staff, and plan for future growth. 0
✔
I consent to receive offers, recommendations, and promotions through direct marketing channels from PLDT’s
business partners. (OPTIONAL)

PRIVACY NOTICE AND CONSENT FORM Depending on the circumstances, such as when we process your Personal Data based on your consent, you may also
Registration with the PLDT Home Rewards Program have the right to object to the processing thereof_ If you believe that your data privacy rights have been violated in
PLDT Inc. ("PLOT") is committed to continuously provide better products, services, and benefits to our customers through your participation in the "PLOT Home Rewards Program", we encourage you to contact PLDT's Data Privacy Officer to
the PLOT Home Rewards Program ("PLOT Rewards")_ PLOT Rewards enables customers to earn points and rewards as they seek resolution of your complaint. You also have the right to go directly to the National Privacy Commission or to make
enjoy PLOT Home services_ PLOT Rewards is operated by PLOT in partnership with MVP Rewards and Loyalty Solutions a claim against PLOT before a competent court.
Incorporated ("MRSI"), a PLOT subsidiary_
To exercise any of your rights, you may get in touch with our Data Privacy Officer through:
To join PLOT Rewards, you are required to register with the Most Valuable Partner Rewards ("MVP Rewards") program of
MRSI. MRSI may process your personal data for purposes in addition to your participation in PLOT Rewards_ To know more PLOT Home Data Privacy Office
about how MRSI processes your personal data, you may email MRSl's Data Protection Officer at [email protected]_ph_ Ramon Cojuangco Building, Makati Avenue, Makati City 1200 Philippines
[email protected]
Cancellation of your MVP Rewards membership will also result in the termination of PLOT Rewards registration and **Acknowledgement and Consent**
forfeiture of any privileges you may have earned under the PLOT Home Rewards program_ However, you may withdraw
your participation in the PLOT Home Rewards program by contacting MRSI through [email protected]_ph_ This will not Jf you allow PLOT and MRSI to process your personal information for the purposes described above, please check the
affect your MVP Rewards account. corresponding consent box/es:

0
I allow PLOT to share my personal information(complete name, mobile number, account number, telephone
Your rights and choices ✔ number, city, email address, and date of birth) to MRS! so that my MVP Rewards account and PLOT Home Rewards
membership may be processed_
The Data Privacy Act gives you certain rights to your personal data_ Subject to exceptions under the law, you are entitled

0
to request: I allow MRSI to contact me by text or email to send me a link where I can register my MVP Rewards registration and
1. Access to the personal data we process about you; ✔ complete my PLOT Home account registration so that I may begin earning "crystals" (Le_ points) and rewards_
2. Rectification of your personal data if it is found to be outdated, inaccurate, or incomplete;

0
3. Erasure of your personal data in cases where it is no longer needed to achieve the legitimate purpose of its I allow PLDT to share my bills payment information to MRSI on a monthly basis for the purpose of determining and
processing; ✔ awarding the corresponding number of crystals that I may earn each month_
4. Restriction of processing of your personal data in limited circumstances;
5. Portability of your personal data so that you may receive a copy thereof or that we transmit the same to another In affixing your Name and Signature below, you confirm that you have read and understood this Consent Form and the
company on your behalf purposes for which your Personal Data will be shared and processed. You also confirm your choices above.
I confirm that I have read, understood and agree to the provisions stated in the Subscriber Declaration section of this form.
I also confirm that I have read, understood and agree to the(]) PLOT Terms and Conditions and Privacy Policy found on PLDTs website at www_pldthome.com/termsandconditions) or in the PLOT Terms & Conditions and Privacy Polley presented to and/or discussed
with me by a PLOT representative during my service application and attached hereto, including any amendments thereto(the "Terms & Conditions"), concerning my subscriptions to PLOT HOME PLANS, as well as Value Added Services identified in the "Tell us about
the Plan you want.__" section of this form and(ii) specific terms and conditions of applicable promos found at www_pldthome.com/termsandconditions or in the specific terms and conditions of appllcable promos presented to and/or discussed with me by a PLOT
representative during my service application and attached hereto_

Customer's signature over printed name Date signed (MM/DD/YY):

ELMON MATUGUINAS RENTASIDA

___,/_--�/___