*Please fill-out the Items as may be applicable

LOAN RECORD FORM

DEPARTMENT/BRANCH From: (mm/yyyy) To: (mm/yyyy)
Tagum Lending Center
COMPANY / CORPORATE NAME / SINGLE PROPRIETOR(*SP/CORP) CIF NUMBER

I.) BENEFICIAL OWNER/S

SALUTATION GIVEN NAME SUFFIX (e.g. MIDDLE NAME LAST NAME AGE
 MR Jr, Sr,I,II)
 MS
DATE OF BIRTH (mm/dd/yyyy) GENDER CITIZENSHIP SSS | GSIS | UMID NUMBER
 MALE  PHILIPPINES
 FEMALE  OTHERS:______________________________ ACR/ICR/SIRV/SRRV NO. (Mandatory if alien)
PLACE OF BIRTH MARITAL STATUS
Town/Municipality/City Province Country  SINGLE
 MARRIED  LEGALLY SEPARATED TAXPAYERS IDENTIFICATION NUMBER
WIDOW/ER ANNULLED/DIVORCED - -
PRESENT ADDRESS
House/Floor/Unit No. Block No./Lot No./Phase No. Street Name Subdivision/Village Barangay Town/Municipality/City Province/Region Country Zip Code

NATURE OF WORK: SOURCE OF FUNDS:

 SALARY  BUSINESS  INVESTMENT PROCEEDS  LOANS PROCEEDS
 INHERITANCE  PENSION/REMITTANCE  COMMISSION/INTEREST  OTHERS(please specify)____________________________
II.) OWNERS/PRINCIPAL STOCKHOLDERS/DIRECTORS/GENERAL MEMBERS/OFFICERS AND PARTNERS
PRINCIPAL OFFICERS (AS OF _____________) POSITION CONTACT NO./S

PARTNERS/MAJOR STOCKHOLDERS (AS OF_____________) POSITION CONTACT NO./S PAID UP CAPITAL % OF OWNERSHIP

(Use additional sheet if necessary) Total: Total:

III.) AFFILIATED COMPANIES & RELATED BUSINESS
NAME % OF OWNERSHIP H.O. / BRANCH (DBP) DEPOSIT/LOANS/NONE (DBP)

IV.) SUPPLIERS
IMPORTED PURCHASES % TO TOTAL PURCHASES

LOCAL PURCHASES % TOTAL PURCHASES

FREQUENCY/MONTHL
CONTACT CONTACT EMAIL ADDRESS PESO/DOLLAR % TO TOTAL PURCHAS
MAJOR SUPPLIERS PRODUCT VOLUME PURCHASES
Y AVERAGE
PERSON NUMBER ADDRESS (CITY,PROVINCE,COUNTRY) E TERMS
PURCHASE
1)
2)
3)

4)
5)
V.) EXPANSION PLANS (if any)
PLANT CAPACITY SALES NETWORK
NEW PRODUCT LINES TOTAL COST
SOURCE OF FINANCING
BORROWING LEVEL PLANS

VI.) CREDIT RELATIONSHIP (Ranked as to size of credit facilities)

BANK/FINANCING/LEASING COMPANY AMOUNT APPROVED SECURITY/GUARANTY

 I/We hereby certify that the above information are true and correct to the best of my knowledge and confirm that I fully understand and agree to be governed by the rules and regulations of the Bank.

Per Board Resolution No. ____ dated, the company/parent company, major stockholders/controlling stockholders, principals, subsidiaries, guarantors, joint and several signatories and/or third party mortgagors also waive
its right/s (I also waive my rights - for individual) to the confidentiality of information and authorizes DBP to:
a. Obtain credit information regarding myself/the company’s credit dealings from: (i) credit bureaus/reporting agencies such as, but not limited to, the Credit Information Corporation, BAP Credit Bureau, Inc., and Credit
Management Association of the Philippines; (ii) banks and/or financing companies/institutions; and (iii) other creditors/lenders, its parent company and other related parties mentioned earlier as a reciprocal service;
b. Regularly submit and disclose credit information pertaining to my/the company’s credit dealings with DBP to the CIC as well as any updates or corrections thereof; and
c. Share credit information pertaining to all of my/the company's credit dealings with DBP with other creditors/lenders and credit bureaus/credit reporting agencies.

ACCOMPLISHED BY: (*If Applicable) RECEIVED BY

Signature over Printed Name/ Date Signature over Printed Name/ Date Signature over Printed Name/ Date
MCL 06217
(Rev 0 – 20Jul17)
 FOR BANK’S USE ONLY
COMPANY / CORPORATE NAME / SINGLE PROPRIETOR CIF NUMBER

VII.) OWNERS/PRINCIPAL OFFICERS/LGU AUTHORIZED SIGNATORIES  Check if same as Item I – Beneficial Owner/s
SALUTATION GIVEN NAME SUFFIX (e.g. MIDDLE NAME LAST NAME AGE
 MR Jr, Sr,I,II)
 MS
DATE OF BIRTH (mm/dd/yyyy) GENDER CITIZENSHIP SSS | GSIS | UMID NUMBER
 MALE  PHILIPPINES
 FEMALE  OTHERS:______________________________ ACR/ICR/SIRV/SRRV NO. (Mandatory if alien)
PLACE OF BIRTH
Town/Municipality/City Province Country
TAXPAYERS IDENTIFICATION NUMBER
- -
PRESENT ADDRESS
House/Floor/Unit No. Block No./Lot No./Phase No. Street Name Subdivision/Village Barangay Town/Municipality/City Province/Region Country Zip Code

VIII.) OTHER DETAILS

MOBILE NUMBER 1 MOBILE NUMBER 2 EMAIL ADDRESS

PERMANENT ADDRESS  SAME AS PRESENT ADDRESS

House/Floor/Unit No. Block No./Lot No./Phase No. Street Name Subdivison/Village Barangay Town/Municipality/City Province/Region Country Zip Code

BUSINESS ADDRESS
House/Floor/Unit No. Block No./Lot No./Phase No. Street Name Subdivison/Village Barangay Town/Municipality/City Province/Region Country Zip Code

Other Dependents: Relationship:

IX.) OFFICER/AUTHORIZED SIGNATORIES BACKGROUND

EDUCATIONAL ATTAINMENT Inclusive Year:
School Attended:
Degree Obtained: Profession or Trade:

WORK EXPERIENCE Annual Income (For Single

Year Position Company Salary Investment Proprietorship)

 P150,000 – P249,999
 P250,000 – P499,999
 P500,000 – P999,999
 Above P1,000,000
X.) SPOUSE DETAILS
SALUTATION GIVEN NAME SUFFIX (Jr, MIDDLE NAME LAST NAME
 MR Sr,I,II)
 MS
EDUCATIONAL ATTAINMENT Inclusive Year:
School Attended:
Degree Obtained: Profession or Trade:

WORK EXPERIENCE
Year Position Company Salary Investment

XI) FINANCIAL BACKGROUND

ASSETS (Real Estate) As of _______________
Encumbrances
TCT/TD No. & Location Market Value Encumbered To
(Y/N)

LIABILITIES As of _______________
Date
Name & Address of Creditors Amount Outstanding Balance Security Remarks
Granted Maturity

* * * (Use additional sheet if necessary) * * *

TOTAL NETWORTH P
Reference (Past credit dealings with Banks, Trade Firms or Private Parties)

POLITICALLY EXPOSED PERSON?  YES  NO Interviewed by: Noted by:

If yes,

Position Signature over Printed Name/ Date Signature over Printed Name/ Date

MCL 06217
(Rev 0 – 20Jul17)