FMDA-0629

AUTHORIZED SIGNATORY
Per Board Resolution / Secretary’s Certificate Dated __________________
CUSTOMER INFORMATION
CORPORATE NAME DATE

SIGNATORY NAME(Last Name, First Name, Middle Name)

DATE OF BIRTH(MM/DD/YYYY) PLACE OF BIRTH GENDER

PRESENT ADDRESS (House No./ Building Name/ Block and Lot No./ Street)

CONTACT NO. E-MAIL ADDRESS NATIONALITY

FATCA DETAILS (If US Citizen or Filipino with Dual Citizenship)

OVERSEAS ADDRESS

OVERSEAS TAX ID NO. OVERSEAS PHONE/ MOBILE NO.

NATURE OF WORK POSITION

SOURCE OF FUNDS* SOURCE OF WEALTH** VOLUME OF ASSETS

*Source of Fund refers to the origin of the funds or other monetary instrument that is the subject of the transaction, or business or professional relationship between a covered person and
its customer, such as cash on hand, safety deposit box with a covered person, and a particular bank or investment account.

**Source of Wealth refers to the resource from which the customer’s wealth, including all monetary instruments and properties, came, comes, or will come from, such as employment,
business, investment, foreign remittance, inheritance, donation, and winnings.