For ACOM CONSUMER FINANCE CORPORATION

Branch/Booth LOAN APPLICATION SHEET

PERSONAL INFORMATION WORK / BUSINESS INFORMATION
FIRST NAME MIDDLE NAME LAST NAME COMPANY NAME DEPARTMENT SUPERSTAFF OPS

AMELITO PREMACIO GALABO JR Logiscale INC OFFICE PHONE NO. EXT. NO.
0915 579 8852

If you are married, please fill out maiden name. OFFICE ADDRESS (Unit No. , Subdivision/Building , Street No. , Barangay , City , Province) ZIP CODE
9F 6780 BUILDING - - - SAN LORENZO MAKATI METRO MANILA 1226

GENDER BIRTH DATE CIVIL STATUS NO. OF TOTAL NO. OF EMPLOYEES TENURE EMPLOYMENT TYPE
(mm/dd/yyyy) DEPENDENTS
■ 1. Male
□ 2. Female
03/03/1989 ■ 1. Single
□ 3. Widowed
□ 2. Married
□ 4. Divorced
0 □ 1. 1-10
□ 3. 51-100
□ 2. 11-50
■ 4. 101-500
3 yrs 0 mo ■ 1. Regular
□ 3. Fixed Period
□ 2. Probation
□ 4. Project
EDUCATIONAL ATTAINMENT PLACE OF BIRTH NATIONALITY □ 5. 501~ □ 5. Part Time □ 6. Self Employee/Freelance
□ 1. High School □ 2. Vocational BUSINESS TYPE
■ 3. College □ 4. Post Graduated MANDAUE CITY, CEBU FILIPINO ■ 1. BPO/IT/Communication/Mass Media □ 2. Retail Sale/Restaurant/Hotel/Tourism/Other Service
□ 5. Others () □ 3. Transportation/Shipping/Real Estate □ 4. Bank/Insurance/Finance
□ 5. Government □ 6. Construction/Maker/Manufacturing
PRESENT ADDRESS (Unit No., Subdivision/Building, Street No., Barangay, City, Province) ZIP CODE
□ 7. Trading/Export/Import/W holesale □ 8. Electric/Gas/W aterworks
- BLOCK 1 - ROWENAS GARDEN DOLORES TAYTAY Rizal 1920 □ 9. Medical/Education/School □ 10. Security
□ 11. Agriculture/Forestry/Fisheries/Mining □ 12. Other()
PERMANENT ADDRESS (Unit No., Subdivision/Building, Street No., Barangay, City, Province) ZIP CODE
- BLOCK 1 - ROWENAS GARDEN DOLORES TAYTAY Rizal 1920 OCCUPATION TYPE
■ 1. Management □ 2. Marketing □ 3. Sales
□ 4. Office W orker □ 5. Professional/Technical □ 6. Service/Reception
□ 7. Production W orker/Labor □ 8. Security/Guard/Maid □ 9. Driver
HOME OWNERSHIP MONTHLY HOME FEE □ 10. Self Employee/Freelance □ 11. Other ( )
(RENTAL /
□ 1. Owned ■ 2. Relative MORTGAGED) 0 Php
□ 3. Rented □ 4. Others()
TERM OF STAY CAR OWNERSHIP POSITION ANNUAL INCOME MONTHLY INCOME PAY DAY
10 yrs 03 mo ■ 1. None
□ 2. Owned/ Monthly Amortization ()Php
■ 1. Director/Officer
□ 3. VP/MG
□ 2. EVP/SVP/GM
□ 4. None 435,500 Php 33,500 Php 15 &
30
HOME PHONE NO. HOME PHONE NAME BUSINESS HOURS
Day Of Week Time Slot Day Of Week Time Slot Day Of Week Time Slot
0963 172 4986 □ 1. Owned □ 2. Relative □ 3. Others( )
(Mon) ~ (Fri) 00:00 ~ 24:00
OS(MOBILE PHONE) PAYMENT TYPE (MOBILE PHONE)
■ 1. Android □ 2. IOS(iPhone) ■ 1. Pre-paid □ 2. Post-paid DAY OFF ■ 1. Mon ■ 2. Tue ■ 3. Wed ■ 4. Thu ■ 5. Fri □ 6. Sat □ 7. Sun □ 8. Other
□ 3. Black Berry □ 4. Others()
MOBILE PHONE NO.
ASSIGNED WORK PLACE INFORMATION
Main 0963 172 4986 COMPANY NAME
Sub Sub
EMAIL ADDRESS OFFICE ADDRESS (Unit No., Subdivision/Building, Street No., Barangay, City, Province) ZIP CODE

[email protected]
TIN NO. OFFICE PHONE NO. EXT.NO.
312-880-341-000

ANOTHER INFORMATION
PURPOSE OF LOAN
□ 1. Living Cost □ 2. School Expense/Tuition Fee ■ 3. Medical/Hospital ●I certify that all information provided in this Application Form is true and correct.
□ 4. Purchasing Appliance □ 5. Travel/Vacation □ 6. Entertainment ●I agree that ACOM CONSUMER FINANCE CORPORATION (hereinafter, "ACOM") will send SMS and email for reminder.
□ 7. Own Business □ 8. Repayment □ 9. Other( ) ACOM is not responsible for the security administration on the phone and email account. It is the borrower’s responsibility.
●ACOM may deny the application as a result of credit check, but ACOM will not have the obligation to disclose the reason of
QUESTIONNAIRE denial or to return my application and other submitted documents.
●I agree that ACOM may obtain the Borrower’s personal information from credit information center, third parties or any other
■ 1. HP □ 2. Leaflet □ 3. SNS □ 4. Store Front relevant source of information for purposes of the credit check, confirmation of employment or other risk management and
□ 5. Refferal( ) disclose the personal information pursuant to applicable laws and regulations. I also agree to waive my rights under R.A.
1405.
FACEBOOK ACCOUNT BORROWING METHOD ●I hereby acknowledge and authorize: (1) the regular submission and disclosure of my basic credit data (as defined under
COOPER ZANDER □ 1. LBC ■ 2. Bank Transfer □ 3. GCash □ 4. PayMaya Republic Act No. 9510 and its Implementing Rules and Regulations to the Credit Information Corporation ("CIC") as well as
any updates; and (2) the sharing of my basic credit data with other lenders authorized by the CIC and credit reporting agencies
Do you have any bank accounts? duly accredited by the CIC.
■ Yes □ No ●I declare that my family and I are not a person in a foreign country, who is an important position in heads of state,
government, central bank or similar institution (including cases where applicable in the past).
●I consent to the processing of my personal information and sensitive personal information contained in this application in
accordance with Republic Act No. 10173 or the Data Privacy Act, for the purpose of processing my loan application and
implementation of the Loan Agreement.
●I agree that notwithstanding the execution of a Loan Agreement, the obligations of the parties therein, including the release
BANK/G-CASH/PAYMAYA INFORMATION of the loan amount by ACOM and payment of the principal amount of the loan and interest, shall be effective only upon
approval by ACOM of my loan application.
(If you chose Bank Transfer) ●I agree that in case I do not have email address or haven't recieved my statement of account and any letters in relation to my
application with ACOM thru my e-mail address, I allow ACOM to send it in my office.
NAME OF BANK/NAME OF G-CASH/PAYMAYA BRANCH
ORTEGAS EXT 2, TAYTAY,
CHINABANK RIZAL

TYPE OF ACCOUNT ACCOUNT NO.

■ 1. Savings □ 2. Checking/Current □ 3. GCash □ 4. PayMaya 144802008629

□ I would like to receive newsletters, advertisements, promotions, offers, and other marketing materials on ACOM’s products and services.
□ I consent to the recording of my conversations with ACOM’s officers, employees, and representatives.

SIGNATURE OF BORROWER DATE (mm/dd/yyyy)

03/28/2024

AMELITO PREMACIO GALABO JR