ANNAPOLIS FINANCE INC.

APPLICATION FORM Form no. 003-9112019

BORROWER'S PERSONAL INFORMATION SPOUSE' PERSONAL INFORMATION
LAST NAME FIRST NAME MIDDLE NAME LAST NAME FIRST NAME MIDDLE NAME
Bleza Meynard Laxamana Bleza Divine Grace Mendoza
Birthday Age Sex Civil Status Birthday Age Sex Civil Status
X Male Single X Married Male Single x Married
01 21 1984 38 Female Separated Widowed 12 26 1984 37 x Female Separated Widowed
Contact Number Contact Number
Education High School Graduate College Graduate Education x High School Graduate College Graduate
High School Level x College Level High School Level College Level
Course BSIT Course
School Last Attended Year Grduated School Last Attended Year Grduated
AMA Computer College 2002
SSS No. TIN SSS No. TIN
Father's Name Melchor E. Bleza Father's Name Reynaldo Mendoza
Mother's Maiden Name Editha Almedina Laxamana Mother's Maiden Name Edelborga Carpentero
Parent's Address Parent's Address
Deceased Deceased
Siblings (Brothers/Sisters) Age Address Siblings (Brothers/Sisters) Age Address
John Malcolm Bleza 36 Bucal Calamba City

3
No. Of Children : _______
Name Age School
David Gabriel M Bleza 15 E Barretto Sr. Nat HS
Graciella Mey Bleza 12 E Barretto Sr. Nat HS
Miguel Inigo Bleza 7 PWD

Present Address: No. Street Village/Subdivision/Barangay Municipality Province Lenght of Stay

45 Mamon Rd. Zone 1 Bagong Kalsada Calamba City Laguna 20 Yrs
Home Ownership: Home Phone
x Owned (not Mortgaged) Owned (Mortgaged) Rented (Php_______/mo.) Used Free
Previous Address: Lenght of Stay Cellphone
09913034069
Provincial Address: Lenght of Stay Email Address

Do you own a motorcycle? No x 1

Yes, how many?________ Yamaha Model:Aerox
Make: ______________ 2019 Plate No.: ______________
_____________
CO-BORROWER INFORMATION (other than spouse)
LAST NAME FIRST NAME MIDDLE NAME Birthday Sex Relation to Borrower
Male
Female
Education High School Graduate College Graduate Course:
High School Level College Level School Last Attended: Year Graduated:
Employment Self-Employed Government Employer/Bussiness Name: DTI/SEC Reg. No.
Private Professional
Employer/Buss. Address: Bldg./No./Street Village/Subdivision Municipality Province Lenght of Stay

Employer/Buss. Address: Position Monthly Income Prof. License No. SSS No. TIN

Previous Employer: Lenght of Stay:

BORROWER'S CHARACTER REFERENCES CO-BORROWER'S CHARACTER REFERENCES

NAME ADDRESS CONTACT NO. NAME ADDRESS CONTACT NO.

PURPOSE OF LOAN:
To be filled up by AFI employee: Checked by:

MASTER LIST

Borrower's 2x2 Photo Co-Borrower's 2x2 Photo Borrower: ____________________________

Spouse: Marketing Staff (Signature)
CB1:
CB2:

UNDERTAKING
I/We hereby certify that all the information furnished in this application form are true, correct and complete, and that the signatures herein are true and genuine. I/We hereby authorize Annapolis
Finance Inc. to obtain such information as may be required concerning the validity and veracity of the information provided in this application using any applicable methods of process, including
my/our loan and deposit account, and waive my/our rights under R.A. 1405. I/We further agree that this application and all supporting documents and any other information obtained by Annapolis
Finance Inc. relative to this application shall remain as Annapolis Finance Inc.'s property whether or not the loan is granted. I/We agree that Annapolis Finance Inc. has no obligation to furnish
me/us the reason for such rejection. I/We also understand that any false statement or concealment of information which may be discovered after the loan has been granted shall be sufficient basis
for Annapolis Finance Inc. to consider the loan due and demandable immeidately. I/We hereby undertake that the proceeds of the loan application if approved shall not be used for placement
purposes and/or to pay any chargeable and allowable fees in relation to my travel and/or work abroad. Otherwise, Annapolis Finance Inc. has the right to disapprove the loan, or if granted
to rescind the contract of the loan and shall declare all unpaid amortization immediately due and demandable together with all interest and damages.

Meynard Laxamana Bleza 08 19 2022

Borrower (Signature Over Printed Name) DATE AGENT NAME

Spouse (Signature Over Printed Name) Co-Borrower (Signature Over Printed Name) (Borrower's Signature Confirmation)