Instructions:
CLIENT INFORMATION SHEET
j Please PRINT all entries legibly and check appropriate boxes k Notify PNB-SAMG of change in address and other information herein mentioned.
INDIVIDUAL
CLIENT rSPOUSE / rCO-BUYER
Name (Last Name, First Name, Middle Name)
Present Address
Permanent Address (If different from present address)
Preferred Mailing Address: r Present Address r Permanent Address r Present Address r Permanent Address
Date / Place of Birth (mm/dd/yy) / /
Tax Identification No. (TIN)
Nationality r Filipino r Others: r Filipino r Others:
Gender r Male r Female r Male r Female
Civil Status rSingle rMarried rOthers: rSingle rMarried rOthers:
LandLine: _______________ Cellphone: _________________ LandLine: _______________ Cellphone: _________________
Contact Details
Email address: Email address:
Identification Card Nos. rSSS rGSIS: ______________rPassport:_____________ rSSS rGSIS: ______________rPassport:_____________
(at least two) rDriver's License rOthers: rDriver's License rOthers:
rElementary rHigh School rCollege rElementary rHigh School rCollege
Educational Attainment
rPost Graduate rOthers: rPost Graduate rOthers:
rEmployed rSelf Employed rRetired rEmployed rSelf Employed rRetired
Employment Status
rOFW rUnemployed rOthers: rOFW rUnemployed rOthers:
Engaged in Business rNo rYes If YES, nature of business: rNo rYes If YES, nature of business:
Office/Business Address
Contact Numbers
SEC/DTI Registration No.
Position:
GROSS MONTHLY INCOME Buyer Spouse/Co-Buyer Total
rSalaries & Allowances _________________ ________________ __________________
rBusiness _________________ ________________ __________________
rOthers (ps. Specify)_______________
________ _________________ ________________ __________________
TOTAL INCOME _________________ ________________ __________________
AUTHORIZED REPRESENTATIVE
Name (Last Name, First Name, Middle Name) Date / Place of Birth (mm/dd/yy) /
TIN: Nationality:
Present Address
Gender: Civil Status:
Permanent Address Employment Status
(If different from present address) rEmployed rSelf Employed rRetired
LandLine: _______________ Cellphone: __________________ rOFW rUnemployed rOthers:
Contact Details
Email address: Educational Attainment
Identification Card Nos. rSSS rGSIS: ______________rPassport:_____________ rElementaty rHigh School rCollege
(at least two) rDriver's License rOthers: rPost Graduate rOthers:
CORPORATE/JURIDICAL
SEC Reg. No. Date
Name of Entity
TIN
Nature of Business Contact details: Landline:_____________________________
Cellphone:___________________________
Official Address
Email:
1._________________________________________________ Position ___________________________________________
Authorized Signatory(ies): 2._________________________________________________ Position:___________________________________________
3._________________________________________________ Position:___________________________________________
OTHER DISCLOSURES
Do you have a relative working at PNB? rYes rNone If Yes, Name of Relative:______________________________ Branch/Dept:_______________
Degree of Consanguinity/Affinity: Relationship:
Do you belong to the LT Group of Companies? rYes rNo If Yes, please specify:
FOR U.S. PERSONS UNDER FOREIGN ACCOUNT TAX COMPLIANCE ACT
Are you a U.S. Person? rYes* rNo *If YES, complete US Permanent Address ______________________________________________________
*Document Presented ? rW-8 BEN Form rW-9 Form *U.S. Social Security Number __________________________________________________
CERTIFICATION
I/WE HEREBY CERTIFY that the above information are true, correct, accurate and complete. I/We also authorize PNB to use
the above information within the bounds of R.A. 10173 otherwise known as the Data Privacy Act of 2012.
_________________________________ ____________ _________________________________ ___________
Signature Over Printed Name Date Signature Over Printed Name Date
FOR PNB USE ONLY
rDOSRI CWS VERIFICATION: rNo Record rRecord Found* ROPA Client ID__________
rRPT *Advised thru email the Compliance Officer Designate on________ ___________ ___________________________ ___________
Emp. No. Name & Signature/Initial Date
