Bldg1 Cainta Business Center, Vista Verde Executive Village Gate2, Brgy.

San Isidro Cainta, Rizal 1900

Tel. No.: (02) 654-7951, 531-4672, 682-2873, 571-5314, 234-1204, 234-0205

CUSTOMER INFORMATION SHEET

Date:
BUSINESS NAME:

BUSINESS ADDRESS:

TYPE OF BUSINESS : { } SINGLE PROPRIETORSHIP { } PARTNERSHIP

{ } CORPORATION { } COOPERATIVE
TELEPHONE NUMBER: TIN / SSS NO.

BUSINESS CLASSIFICATION: { } SUPERMARKET { } GROCERY { } DEALER

{ } CORPORATIOIN { } CANTEEN { } FOOD CHAIN
OTHERS, PLEASE SPECIFY _________________

OWNER'S NAME:

HOME ADDRESS:

BIRTHDAY: TELEPHONE NO. (RES.) :

TELEPHONE NO. (BUSINESS):
SEX { } MALE CIVIL STATUS: { } SINGLE { } MARRIED
{ } FEMALE { } WIDOW (ER) { } SEPARATED
SPOUSE NAME:

BANK ACCOUNTS :
NAME OF BANK, BRANCH TYPE OF ACCOUNT ACCOUNT NUMBER

CREDIT REFERENCES:
NAME OF BANK / INSTITUTION TYPE OF PLAN CONTACT PERSON TEL.NO.

TRADE REFERENCES (MAJOR SUPPLIERS WITH WHICH THE COMPANY HAS CREDIT LINE. PLEASE ATTACH TWO (2)
PHOTOCOPIES OF SUPPLIER'S INVOICES.

SUPPLIERS:
NAME OF SUPPLIERS CONTACT PERSON TEL. NO. CREDIT LIMIT CREDIT TERMS

CUSTOMERS:
NAME OF SUPPLIER CONTACT PERSON: TELEPHONE NO.:
_________________________
_________________________
_________________________

PERSONNEL AUTHORIZED TO PLACE ORDERS IN COMPANY'S BEHALF:

NAME POSITION SPECIMAN SIGNATURE

PERSONNEL AUTHORIZED TO RECEIVE STOCKS IN COMPANY'S BEHALF:

NAME POSITION SPECIMAN SIGNTURE

I/WE GIVE THE ABOVE INFORMATION FOR THE PURPOSE OF OBTAINING A CREDIT LINE IN THE AMOUNT OF
PESOS: _______________________________________________________ (P_____________) WITH A CREDIT TERM OF
________ DAYS.

BY SIGNING BELOW, I CONFIRM THAT THE INFORMATION GIVEN BY ME IS TRUE AND CORRECT. I/WE
AUTHORIZED KALINISAN CHEMICALS CORPORATION OR IT'S AUTHORIZED REPRESENTATIVE TO OBTAIN,
BACKGROUND CHECK, INQUIRE AND/OR VERIFY INFORMATION FROM OUR BANKS, TRADE SUPPLIERS,
CREDITORS AND OTHER AVAILABLE SOURCES REGARDING ANY STATEMENT, DATA MADE HEREIN OR FROM
WHATEVER SOURCES YOU MAY CONSIDER APPROPRIATE. I UNDERSTAND THAT MY APPLICATION MAY BE
DENIED FOR ANY REASON WHATSOEVER AND YOU HAVE NO OBLIGATION TO FURNISH THE REASON FOR THE
REJECTION.
______________________________
SIGNATURE OVER PRINTED NAME

_______________ _________
POSITION/TITLE DATE

REQUIRED DOCUMENTS TO SUPPORT THIS APPLICATION FORM

FOR SOLE PROPRIETORSHIP:

1. CURRENT MAYOS'S PERMIT

2. DTI CERTIFICATE OF REGISTRATION
3. INCOME TAX RETURN
4. BANK STATEMENT

FOR CORPORATION/PARTNERSHIP/COOPERATIVE

1. CURRENT MAYOR'S PERMIT

2. DTI CERTIFICATE OF REGISTRATION
3. SEC CERTIFICATE OF REGISTRATION
4. ARTICLES OF INCORPORATION/PARTNERSHIP
5. INCOME TAX RETURN
6. CERTIFICATE OF REGISTRATION (BIR Form 2303)

FINANCE DEPARTMENT USE ONLY:

RECOMMENDATION APPROVAL

AMOUNT: _____________________ AMOUNT _______________________

TERMS: _____________________ TERMS _______________________

RECOMMENDED BY: __________________ APPROVED BY: _________________

NOTED BY: ________________________