MOTOR VEHICLE LOAN APPLICATION FORM

(For Individual/Sole Proprietorship)

NOTE: Print in 8.5” x 14” paper size (Print on Both Sides)

DEALER’S NAME SALES REPRESENTATIVE BRANCH/OFFICE APPLICATION DATE

DEALER’S
INFORMATION
LOAN APPLICATION INFORMATION
Description of Unit (Brand, Model, Year) Place of Issue Loan Purpose
Private/Personal Business
Public
List Cash Price Downpayment Amount Financed Manner of Payment
A. Required Down Payment/Chattel Mortgage Fee/Insurance Premiums B. Monthly Amortization
Post Dated Checks
Loan Term (Months) Cash Check
Debit PNB Account
12 24 36 48 60 Others _________ Debit PNB Account No. _______________________
No. _______________________________
Last Name First Name Middle Name Date of Birth (mm/dd/yyyy) Place of Birth Age

Gender Civil Status No. of Dependents Citizenship ACR No. Mobile No. Landline No.
PERSONAL INFORMATION

✔ Male ✔ Single Widowed Annulled

Female Married Separated 0 Filipino 09056626323
Maiden Name (For Female Married Borrowers) Mother’s Maiden Name Highest Educational Attainment TIN / UMID / SSS / GSIS No. Email Address
Grade School ✔ High School
Sonia Diaz Ramos College Post Graduate
2639922077000 [email protected]
Present Home Address (Unit No./ Floor, Building Name, Building/House No., Street, Barangay, City/Municipality, Province, Zip Code)

Sunries Apartment, Sandoy St, Alaminos City, Pangasinan 2404.

Permanent Address Same as Present Home Address (Unit No./ Floor, Building Name, Building/House No., Street, Barangay, City/Municipality, Province, Zip Code)

388 Siteo Malikto, Talogtog Mangaldan, Pangasinan 2404. / Brgy Mona Alaminos City, Pangasinan
Contact No. Length of Stay Home ✔
Owned Home Living with Relatives Rented
09056626323 Mangaldan 36yrs / Alaminos 3Yrs Ownership Owned but Mortgaged with ___________________________________
Are you an Officer, Director or Stockholder of PNB, or any other PNB subsidiaries Are you related to an Officer, Director or Stockholder of PNB, or any other PNB subsidiaries
and/or affiliates? Yes ✔ No If Yes, pls. specify company and and/or affiliates? Yes ✔ No If Yes, pls. specify name/s and relationship
position/affiliation_____________________________________________________ __________________________________________________________________________
Employer / Business Name Employer / Business Address
Milrey's Place Since2021 & Quadro Pizza Hub EJR Business Center, Marcos Aveneu, Palamis, Alaminos City Pangasinan 2404.
EMPLOYER / BUSINESS

Position / Title Basic Salary/Monthly Income Contact No. Email Address

CEO/OWNER SALARY 30 09277804359 [email protected]
INFORMATION

Status Other Monthly Income Yrs. w/ Present Employer /In Business Total Yrs. of Working Experience
✔ Regular Probationary Contractual Business My own Business 3years
Nature of Employment/Business
✔ Accommodation & Food Services Activities Construction Information & Communication Transportation
Activities of Private Household as Employers Education Manufacturing Water Supply, sewerage, waste
Administrative & Support Service Activities Electricity, Gas, Steam, & Air-conditioning Supply Mining & Quarrying management & remedation activities
Agriculture, Forestry & Fishing Financial & Insurance Activities Professional, Scientific & Technical Services Wholesale & Retail Trade
Arts, Entertainment & Recreation Human Health & Social Work Activities Real Estate Activities Other Service Activities
Previous Employer Contact No. Email Address

Last Name First Name Middle Name Date of Birth (mm/dd/yyyy) Mobile No./Landline No.
CO-BORROWER

Laguisma Mildred Laya 08/19/1977 004306707754088

INFORMATION
(If Applicable)
SPOUSE /

Employer/Business Name Employer/Business Address Telephone No./Extension/Local No.

Kurantoin Wiener Pensionisten Wohnhaeuser Viana Austria 004306707754088

Position/Title Basic Salary/Monthly Income Other Monthly Income Status Total Yrs. of Working Experience
nurse 170,000.00 ✔ Regular Probationary Contractual 1yr

Bank Account Number Account Type Date Opened Average Daily Balance
ACCOUNTS
DEPOSIT

PNB 207670005674 BUSINESS 030723

PNB 208310085269 Debit Card

PNB 207610236559 Joint Account 012921

Ave. Monthly
Bank Card Number Member Since Expiry Date Outstanding Balance Credit Limit
Payment
CREDIT CARDS

Lending Institution Loan Type Loan Amount Term Availment Date Maturity Date Monthly Amortization Outstanding Balance
LOANS

Company Name Complete Address Tel. No. Amount of Line Credit Limit
CUSTOMERS
MAJOR

Company Name Complete Address Tel. No. Amount of Line Credit Limit
SUPPLIERS
MAJOR

Form No. RLG001A Rev. Sept. 2022

 OTHER TERMS AND CONDITIONS

I/We hereby certify that all the information and documents furnished to PHILIPPINE NATIONAL BANK (the “Bank”) in connection with this application are true and correct in all material
respect. Should any of the information provided herein be found false or misleading, the Bank may disapprove this application.

I/We further agree that in case of any information and/or provisions herein require updating, the Bank may require submission of a new application form or any document to update
pertinent information/provisions in this form, as the case may be.

I/We acknowledge that pursuant to Republic Act No. 9510 (Credit Information System Act), the Bank is mandated to submit or disclose my basic credit data to the Credit Information
Corporation (CIC) as well as any updates or corrections thereof, and share said credit data with other authorized lenders and duly accredited reporting agencies.

I/We hereby authorize the Bank to: (i) obtain additional information as may be required concerning this application; (ii) verify the completeness and accuracy of the information given with
third parties, including tax authorities and government entities; (iii) share personal information with its accredited third-party service providers, credit entities and authorized representatives
for (a) the processing of this application; (b) the prevention and detection of fraud; and (c) the investigation and/or resolution of fraudulent transactions; and (iv) send announcements and
marketing offers of the Bank’s products and services through email, mail, phone call, SMS/text, social media and digital channels or other means of communication.

I/We hereby authorize the Bank to retain information related to this application whether or not the loan was granted and even after the cancellation or closure of the loan availment or
termination of relationship or services with the Bank until the expiration of retention limit set by laws and regulation.

I/We hereby acknowledge to contact PNB Data Protection Officer at [email protected] should I/we want to access, update, or correct certain personal information, or withdraw the
consent to the processing of personal information provided in connection with this application.

Consent for Cross-Selling

I/We Agree Disagree to share my/our information with the Bank’s subsidiaries, affiliates, and related companies to offer or promote their products and services that would be suitable
or may be of interest to me/us. I/We understand that my consent for cross-selling will not affect the result of my/our application herein.

I/We hereby hold the Bank, its subsidiaries, affiliates, correspondent banks, related companies, and third-party service providers, as well as their respective directors, officers, employees
and authorized representatives, free and harmless against any and all claims, liabilities, suit and damages that may arise from: (1) the exercise of the authorities granted herein, and (2) the
use, processing, verification, gathering, transfer, disclosure or sharing of information made pursuant to this Agreement; provided that such claim, liability, suit and damage did not arise from
bad faith, willful misfeasance or gross negligence on the part of the Bank.

This authorization and consent shall be valid and effective until expressly revoked or termination of the purpose for which they were given.

Finally, I/We confirm that I/we have read and understood the terms and conditions herein provided and that I/we are entering into this transaction with my/our full consent.

SIGNATURE OF BORROWER/MORTGAGOR OVER PRINTED NAME/DATE SIGNATURE OF SPOUSE/CO-BORROWER/CO-MORTGAGOR OVER PRINTED NAME/DATE

PNB CREDIT CARD

By signing in this section, I/We hereby manifest my/our intention to apply for and avail of the credit card/s issued by the Bank. I/We undertake to provide additional information and submit
other supporting documents as may be deemed necessary by the Bank. I/We authorize the Bank to conduct necessary credit investigation and verification with government agencies or third
parties to ascertain my/our credit standing and financial capability, and to establish authenticity of the information declared and/or documents submitted in connection with my/our application
for PNB credit card/s. I/We understand that the issuance of the PNB credit card/s to me/us shall be subject to credit evaluation by and discretion of the Bank. I/We hereby agree to be bound
by terms and conditions governing the PNB credit cards and further agree that the activation and/or actual use of the PNB credit card/s shall be deemed my/our acceptance thereof and
consent thereto.

SIGNATURE OF BORROWER/MORTGAGOR OVER PRINTED NAME/DATE SIGNATURE OF SPOUSE/CO-BORROWER/CO-MORTGAGOR OVER PRINTED NAME/DATE

I am/we are NOT interested to apply for or avail a PNB Credit Card.

FOR BANK’S USE ONLY

Received from Loan Applicant By/Date Received for Processing By/Date Approved/Disapproved/Deferred By/Date Remarks

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
Form No. RLG001A Rev. Sept. 2022

PNB is regulated by the Bangko Sentral ng Pilipinas.