CASH ADVANCE APPLICATION FORM DATE: ‘APPLICATION NO. 4 I. CREW INFORMATION RANK / NAME: <{e00K ESCOSIA MELGUIANES §- @ excrew vesset une-up: M/V Ultra Esterhazy_ C New crew TARGET JOINING DATE OR DATE EMBARKED / PORT (if known} Fro work? 7] yes [] No I. CASH ADVANCE APPLICATION DETAILS REQUESTED CASH ADVANCE AMOUNT, PHP REASON FOR CASH ADVANCE: FINANCIAL ASSISTANCE IS THIS YOUR FIRST TIME TO APPLY FOR CASH ADVANCE WITH THE COMPANY? ___[_] veS [7] ANYOUTSTANDING ACCOUNT? [_] Yes NO ifyes,howmuch; i. A. DEDUCTION DETAILS iu. 8. DEPOSIT DETAUS ‘ACCOUNT NAME RN estan ACCOUNT NAME : ql ACCOUNT # ‘ACCOUNT # 14424 BANK BP. BANK ALLOTMENT AMOUNT _|000 NO. OF MONTHS: IV. TERMS / AUTHORIZATION \ understand and accept that ‘A. The principal cash advance amount shall be paid in equal monthly installments; B. Interest will be charged starting from the date the cash advance amount/check is released and will cease upon full payment of the principal cash advance amount; C_ The monthiy installment amount plus interest, will be deducted from my nominated allotment account and shall be payable in the number of months stated in box IIA; . Deduction shall start from my fist full allotment. Any outstanding balance of the principal amount plus interest will be deducted from my final pay, leave pay, and/or any other receivables from the company/vessel. | hereby authorize SOUTHFIELD AGENCIES, INC. to deduct the monthly installment amount plus interest from my nominated allotment account stated in box IIA, | further declare that this authorization is voluntarily signed, with full knowledge that this is an obligation | am legally bound to repay. WITNESS: Tr Fleet Supervisor Fleet Manager int name and Signature Print name and Signature V. ENDORSEMENT / APPROVAL Vi. FOR ACCOUNTING DEPARTMENT ONLY Check No. Received By Frnt name and Signature Amount Date