Mitsukoshi Motors Phils. Inc.

Grocery Pack Claim Stub

Branch Name: V8 RACER TALIBON

No. Customer Name Account number Model Engine no. Chassis no. Date release Signature of customer

10

I/We hereby certify that the abovementioned details herein stated are true and correct based on our/my knowledge and actual release of brand new motorcycle unit to the customer/s. I/We further attest under the penalties of law that the details referred herein
are free of misstatement and/or misrepresentation. Our/My signature below certifies that I/We attesting to the accuracy of this claim stub. In case of any act or nature of negligence that that my resulted to damages and loss to the management, I/We hereby
authorized Mitsukoshi Motors Phils. Inc. to deduct automatically from our/my regular payroll/terminal pay the amount necessary for the restoration/replacement of said grocery items.

Checked by: Confirmed by:

MARYLYN G. SUMALINOG MARYLYN G. SUMALINOG/ MHELJUN O. BALUCA

Signature Over printed name of Cashier Signature Over printed name of Cashier Branch Manager / Officer in-
charge