(ver.02.

02/2019) CREDIT APPLICATION FORM

Kindly provide your answers as truthful as possible so that we can properly evaluate and
Improving Lives, Creating process your application. All information will be treated as strictly confidential
Opportunities
Thank you for your interest in applying for a loan. We value your business and the social mission that you have adopted, thus,
we would like to know more about you and your enterprise.

Borrower’s Information

Full Name: Age:

Date of Birth: Place of Birth: Marital Status: Gender:
Email add: Landline: Mobile No.:
Present Address: Length of Stay: yrs.
Spouse Name: Age:
Contact No.: Email Add: Employment:

Enterprise Information
Registered Name: Years in Operations:
Business Address: Contact No.
Business Activity: Manufacturing Processing Services Trading Others
Industry: Agri-related Handicraft Food Others
Describe your Assets Size: < P 3.0M
business: > P 3.0M to 10.0Mn
> P 10.0M
Gross Sales/Mon: Net Income/Mon. Monthly Tax
Employee Count: Total Female: Regular Average age
Ave. Salary/Mon: Average Educational Attainment:

Loan Requirement
Amount Requested Purpose:
Months to Pay: Mode of Payment:
Security to Offer: Valuation:

Impact Generation (directly resulting from this requested loan)

Additional Income to be Generated Additional Jobs:
New Assets to be Acquired: Additional Tax:
Other Impacts to be Generated:
Impact Areas of this Loan: (please check applicable impact)
Woman Empowerment Health Improvement Food/Water Security
Renewable/Clean Energy Waste Recycling Education
Preferred Sector Promotion Environmental Protection Rural Development
Indigenous Group Countryside Build-up Others: _____________

Character References:
Name Contact Number Business Dealings

Important Notes:
I have voluntarily given all information stated above to serve as credit loan application information requirements. Pursuant to
Republic Act No. 10173 (Data Privacy Act of 2012) and its Implementing Rules and Regulations, I hereby give my consent to SME-ICC :
(1) to use, process, file and create a data profile of the aforementioned information, as well as other necessary information derived
from my loan interview, for the purpose of its credit evaluation and background investigation in relation to my loan application; and
(2) to preserve such information or data profile for as long as I have an outstanding loan with SME-ICC. I am also giving SME-ICC full
authority to take pictures of myself and my business and use the same in its marketing and promotions drive/campaign in print, on-
line and other media.
I hereby authorize SME-ICC to obtain, check, verify, and inquire with any private or government agency such information pertinent for
them to assess my loan application.
I also authorize SME-ICC to: (1) regularly report or submit to the Credit Information Corporation (CIC) my basic credit data as defined
under Republic Act no. 9510 and its implementing Rules and Regulations, as well as any updates or correction thereof; and (2) share
my basic credit data with other lenders authorized by the CIC and credit reporting agencies duly accredited by the CIC. I further
authorize SME-ICC to share my basic credit data with the Credit Management Association of the Philippines (CMAP).

________________________________ ____________ ___________________________

 (ver.02.02/2019) CREDIT APPLICATION FORM
Kindly provide your answers as truthful as possible so that we can properly evaluate and
Improving Lives, Creating process your application. All information will be treated as strictly confidential
Opportunities
Printed name and Signature of Applicant Date Received by: SME ICC Staff