PERSONAL LOAN

APPLICATION FORM
Is this your first loan with Pahiram? If No, please indicate your Loan Account Number (2020xxxx-LBxxx.). If Yes, leave this blank.
Yes
Do you have existing loans with other financial institutions? If Yes, please indicate financial institution. If None, leave this blank.

How did you learn about Pahiram? Would you like to avail of our Pahiram Debit Card?
Facebook Others: ________________    Yes    No

LOAN DETAILS
DESIRED LOAN AMOUNT DESIRED PAYMENT TERMS (# of Weeks / Months) PAY-OUT OPTION
PHP 1000 8 weeks Union Bank
PURPOSE OF LOAN PAY-IN OPTION
Gadget purchase for Online Learning ECPay / 7-Eleven
PERSONAL INFORMATION
FIRST NAME MIDDLE NAME LAST NAME
Kim Carlo Mita Cortez

MOTHER’S MAIDEN NAME SEX BIRTH DATE (MM/DD/YYYY) AGE NATIONALITY

Imelda Beltran Mita   Male    Female 09/10/1991 28 Filipino

CIVIL STATUS EMAIL ADDRESS MOBILE NUMBER

   Single Married Widowed Separated night.fury0010@gmail.com 09056600153

PRESENT ADDRESS
House / Unit / Flr #, Bldg Name, Blk or Lot # Street

#305 Purok 6

City / Municipality Province Barangay Zip Code

Cabanatuan City Nueva Ecija Bantug Norte 3100

SOURCE OF FUNDS
SOURCE OF INCOME EMPLOYER / BUSINESS NAME
Employed Others: ________________ Ziontech Enterprise

OCCUPATION MONTHLY SALARY POE PHONE NUMBER

IT Officer PHP 25000 044-456-9003
REQUIRED DOCUMENTS
PROOF OF ADDRESS SOCIAL MEDIA PLATFORMS Please enter the email address / user ID
Utility Bill Facebook night.fury0010@gmail.com / night.fury010

GOVERNMENT ISSUED ID - 1 GOVERNMENT ISSUED ID - 2

ID Type ID Number ID Type ID Number

Passport EC4498459

ATTACHMENT CHECKLIST
Proof of Address Government Issued ID - 1 Government Issued ID - 2

   Bill/Statement    Government ID - 1   Selfie with ID - 1    Government ID - 2   Selfie with ID - 2

CHARACTER REFERENCE - 1
Full Name (First Name, Middle Name, Last Name) Relationship Mobile Number

Bryan P Reyes Friend 09161101042

CHARACTER REFERENCE - 2
Full Name (First Name, Middle Name, Last Name) Relationship Mobile Number

Elpidio M Barreo Friend 09155991189

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to
be used to determine the amount and conditions of the loan. Furthermore, I hereby authorize the financial institutions listed on this loan application to
release necessary information to the company for which loan is being applied for in order to verify the information contained herein.

FULL NAME DIGITAL SIGNATURE DATE

Date: 2020.08.16
Kim Carlo M. Cortez 18:40:31 +08'00' Aug 16, 2020