For ACOM CONSUMER FINANCE CORPORATION

Branch/Booth LOAN APPLICATION SHEET

PERSON AL IN F ORMATION W ORK / BU SIN ESS IN F ORMATION
FIRST NAME MIDDLE NAME LAST NAME COMPANY NAME DEPARTMENT sales

PABLITO DAAN PETALLAR JR PROGM21 PH Corp OFFICE PHONE NO. EXT. NO.
0

If you are married, please fill out maiden name. OFFICE ADDRESS (Unit No. , Subdivision/Building , Street No. , Barangay , City , Province) ZIP CODE
room 2 0 square 1 singson vill tipolo mandaue city Cebu 6014

GENDER BIRTH DATE CIVIL STATUS NO. OF TOTAL NO. OF EMPLOYEES TENURE EMPLOYMENT TYPE
(mm/dd/yyyy) DEPENDENTS
■ 1. Male
□ 2. Female
11/17/1973 ■ 1. Single
□ 3. Widowed
□ 2. Married
□ 4. Divorced
0 ■ 1. 1-10
□ 3. 51-100
□ 2. 11-50
□ 4. 101-500
0 yrs 4 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 BOHOL 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/Wholesale □ 8. Electric/Gas/Waterworks
NA NA N Bacalso NA Sitio Didos Linao Talisay CEBU 6045 □ 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
NA NA N Bacalso NA Sitio Didos Linao Talisay CEBU 6045 OCCUPATION TYPE
□ 1. Management □ 2. Marketing ■ 3. Sales
□ 4. Office Worker □ 5. Professional/Technical □ 6. Service/Reception
□ 7. Production Worker/Labor □ 8. Security/Guard/Maid □ 9. Driver
HOME OWNERSHIP MONTHLY HOME FEE □ 10. Self Employee/Freelance □ 11. Other ( )
(RENTAL /
□ 1. Owned ■ 2. Relative MORTGAGED) 1,000 Php
□ 3. Rented □ 4. Others()
TERM OF STAY CAR OWNERSHIP POSITION ANNUAL INCOME MONTHLY INCOME PAY DAY
04 yrs 07 mo ■ 1. None
□ 2. Owned/ Monthly Amortization ()Php
□ 1. Director/Officer
□ 3. VP/MG
□ 2. EVP/SVP/GM
■ 4. None 195,000 Php 15,000 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
0 □ 1. Owned □ 2. Relative □ 3. Others( )
(Mon) ~ (Sat) 08:00 ~ 17:00 (Mon) ~ (Sat) 08:00 ~ 17:00 (Mon) ~ (Sat) 08:00 ~ 17:00
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(none)
MOBILE PHONE NO.
ASSIGNED WOR K PLACE INFOR MATION
Main 0977 377 2032 COMPANY NAME
Sub 0977 377 2032 Sub 0977 377 2032
EMAIL ADDRESS OFFICE ADDRESS (Unit No., Subdivision/Building, Street No., Barangay, City, Province) ZIP CODE

[email protected]
TIN NO. OFFICE PHONE NO. EXT.NO.
909-040-061-000

ANOTHER INFOR MATION

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.
●I agree that ACOM CONSUMER FINANCE CORPORATION (hereinafter, "ACOM") will send SMS and email for reminder.
■ 4. Purchasing Appliance □ 5. Travel/Vacation □ 6. Entertainment ACOM is not responsible for the security administration on the phone and email account. It is the borrower’s responsibility.
□ 7. Own Business □ 8. Repayment □ 9. Other( ) ●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
disclose the personal information pursuant to applicable laws and regulations. I also agree to waive my rights under R.A.
□ 5. Refferal( ) 1405.
FACEBOOK ACCOUNT BORROWING METHOD ●I hereby acknowledge and authorize: (1) the regular submission and disclosure of my basic credit data (as defined under
Republic Act No. 9510 and its Implementing Rules and Regulations to the Credit Information Corporation ("CIC") as well as
pabz daan dela torre misa □ 1. LBC □ 2. Bank Transfer ■ 3. GCash/PayMaya any updates; and (2) the sharing of my basic credit data with other lenders authorized by the CIC and credit reporting
Do you have any bank accounts? agencies duly accredited by the CIC.
●I declare that my family and I are not a person in a foreign country, who is an important position in heads of state,
□ Yes ■ No 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
of the loan amount by ACOM and payment of the principal amount of the loan and interest, shall be effective only upon
BANK/G- CASH/PAYMAYA INFOR MATION approval by ACOM of my loan application.
●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
(If y ou chose B ank T ransf er) 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

PABLITO PETALLAR JR
TYPE OF ACCOUNT ACCOUNT NO.

□ 1. Savings □ 2. Checking/Current ■ 3. GCash/PayMaya 09773772032

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

SIGNATUR E OF BOR R OWER D ATE (mm/dd/yyyy)

07/31/2022

PABLITO DAAN PETALLAR JR