CUSTOMER INFORMATION SHEETRM NO.

___________________________
Last Name First Name Middle Name Suffix
Anggot Edmond Philip Dalagon xx
Date of Birth (mm-dd-yyyy) Place of Birth Nationality Gender
Personal
Information Quezon City, NCR Filipino  M  F

Marital Status Mother’s Maiden Name (Last, First, Middle) Primary Email Address
 Single  Married Dalagon, Elvira Sugano edmondphilipanggot@gmail.com
 Others (please specify):__________________
Contact Mobile (Country Code + Area Code + Tel no.) Landline (Country Code + Area Code + Tel no.) Secondary Email Address
Information +63 945 201 4771 xx xx
House/Unit no., Floor & Building, Street, Lot/Block, Barangay/Village
Blk 4 Lot 41A, Yakal Rd., Acacia Park Homes, Brgy. Saimsim
Present Address
District/Town City/Province Country Zip Code
xx Calamba, Laguna Philippines 4027
House/Unit no., Floor & Building, Street, Lot/Block, Barangay/Village
Permanent Blk 4 Lot 41A, Yakal Rd., Acacia Park Homes, Brgy. Saimsim
Address District/Town City/Province Country Zip Code
xx Calamba, Laguna Philippines 4027
Mailing Address  Present Address  Permanent Address
Nature of Work (Job Title)* Name of Employer/Company/Business Name (if self-employed) Nature of Self-employment / Business**
Please choose one Analog Devices Inc. MFG

Financial TIN or SSS No. or GSIS No. Reason for No TIN or SSS No. or GSIS No.
Information 330-794-117 04-3747761 xx xx
Source of Funds*** Expected Average Deposit Balance
(*Refer to reverse xx
S
side)
Type of Account to be Availed
 Savings  Checkin  Time Deposit  Investment Others: xx
g
 I am not  I am a U.S. Person  I am not a U.S. Person but with U.S. Indicators
a U.S. Person
 U.S. Citizen  U.S. Place of Birth (1 & 2) Required Documents (Submitted)
 U.S. Resident (Green Card)  U.S. Telephone Number (1)  1. W8 BEN
 U.S. Address (1)  2. Any of the following:
U.S. TIN: xx  With Power of Attorney/Signatory (1)  a. Certificate of Loss of US Nationality
U.S. ID: xx  With Standing Instruction (1)  b. Written explanation of not having
 W9 (Submitted)  In care of/Hold Mail (1) such certificate despite the
renunciation
FATCA Declaration  c. Written explanation on why US
and Authorization citizenship not obtained at birth

I certify that all information provided herein are true, accurate and complete, and I agree to promptly inform the Bank of any changes thereto. I authorize
the Bank to rely upon my declaration herein and, if I am a US Person or have US indicators that render my account reportable under FATCA, I consent to
the reporting and disclosure of the required information by the Bank to the Internal Revenue Services (IRS) and/or Bureau of Internal Revenue (BIR) in
compliance with FATCA. In consideration of the foregoing, I agree to hold the Bank, its directors, officers, employees, representatives and agents free and
harmless from any liability, action and suits, costs, and expenses, arising from or in connection with the Bank’s compliance with FATCA regulations and/or
as a result of disclosure made to the US IRS and/or BIR. The consent given herein is deemed to be the consent required under the bank deposit
confidentiality laws in the Philippines or in other jurisdictions including but not limited to RA 1405 (The Law on Secrecy of Bank Deposits), RA 6426 (The
Foreign Currency Deposit Act) and RA 8791 (The General Banking Law) and the consent required under the data privacy laws of the Philippines or of
other jurisdictions, including, but not limited to, RA 10173 (The Data Privacy Act).
.

By signing this form, I hereby certify that the information I provided herein is true, accurate and complete, and I agree to notify/update the Bank of any
change in any of the information supplied in this form.

I acknowledge to have read, understood and agreed to be bound by the terms and conditions of the deposits, products, services, facilities and/or
channels which I opened/availed which were provided and/or are made available to me via www.bpiexpressonline.com, as the same may be amended
from time to time. I likewise acknowledge to have read and understood the Bank’s Data Privacy Statement posted on www.bpiexpressonline.com and in
Certification and the branch premises and I agree that the Bank and/or its agents may process, obtain, collect, record, organize, store, update, modify, use, access, share
Authorization and/or disclose information relating to me and/or my account(s) as described in said Data Privacy Statement. As used herein, the term “Bank” shall
include the Bank’s local or foreign branches, subsidiaries or affiliates (collectively, the BPI Group of Companies), and their respective agents,
representatives and outsourced service providers, as well as the latter’s respective outsourced providers under an obligation of confidentiality. The
consent given herein is deemed to be the consent required under the bank deposit confidentiality laws in the Philippines or in other jurisdictions
including but not limited to RA 1405 (The Law on Secrecy of Bank Deposits), RA 6426 (The Foreign Currency Deposit Act) and RA 8791 (The General
Banking Law) and consent required under the data privacy laws of the Philippines or of other jurisdictions, including, but not limited to, RA 10173 (The
Data Privacy Act).

FOR BANK USE ONLY

Member: PDIC. Maximum Deposit Insurance for Each Depositor: Php500,000 071417
 CLE – Clerical / Rank and File OFW – Overseas Filipino Worker SEL – Self-employed
Nature of CON – Contractual / Proby PRO - Professional STU – Student
FOA – Foreign Ambassador / Diplomat REL – Religious Leader TEC – Technical / Computer
Work (Job
GOV – Government (Elected / Appointed), Please specify RET – Retired HWF – Housewife
Title)* MGR – Mgr / Supervisor / Middle Level SAL – Sales Rep OTH – Others, Please Specify
MGT – Top Management / Senior Level SEA – Seafarer
ACT - Accounting / Bookkeeping / Tax Practice / Services INS - Insurance Activities
ADS - Advertising / Marketing / Sales Activities LAW - Lawyer (Private Practice)
AGR - Agriculture / Hunting / Forestry / Animal Farming / LEG - Legal Practice
Fishing LSE - Leasing / Rental Activities (e.g., Land, Building,
ARC - Architect Machinery, etc.)
BHS - Beauty and Health Services (e.g., Spa, Beauty parlors, MED - Medical Services (includes caregiving)
Fitness Centers) MFG - Manufacturing (Non-food, e.g., Garments, Vehicles,
BNK - Banking Jewelry, Heavy Equipment, etc.)
BPO - Business Process Outsourcing (e.g., Call Centers, Billing / MIL - Military – NP
Credit / Collections, etc.) MIN - Mining
BRO - Brokerage MNF - Manning or Employment Agencies - Foreign
CHA - Charities MNL - Manning or Employment Agencies – Local
CMT - Commodities Trader NGO - Foundation (NGO)
Nature of Self- COM - Communication (Telecommunications includes postal) OPS - Other Professional Services (e.g., Delivery, Photography,
employment / CSY - Consultancy (e.g., Computer-related Consultancy- Catering, Interior Design, Fashion, Design Styling, etc.)
hardware/software, Technical Engineering/Architectural, PUB - Publishing / Printing / Reproduction of Recorded Media
Business /
Scientific Related Consultation, Business Consultancy) PWN - Pawnshops
Company CTN - Construction (e.g., Building, Plumbing, Electrical, RCY - Recycling
where you Carpentry) REL - Real Estate (e.g., development, sales, etc.)
work for** DOC - Doctor / Dentist (Private Practice) REM - Remittance Agent
EDU - Education (including private tutorials, special education) REO - Religious Organization
EMB - Embassies / Foreign Consulates REP - Repairs Services
ENG - Engineer (Private Practice) SAN - Sanitation / Cleaning / Housekeeping Services (e.g.,
ENT - Entertainment (Recreational / Cultural / Sporting Janitorial Services, Building Maintenance, Laundry, etc.)
Services) (e.g., Party Planning Services, Event Organizing, SHP - Maritime or Shipping
Carnival Rides Rental, Fireworks, Displays, Media TOU - Tourism (e.g., Hotels, Inns, Resorts, Tour Agencies,
Network, Film Production, etc.) Restaurants)
FDI - Food Industry / Food Manufacturing / Food Preparation TRA - Wholesale / Retail Trade
/ Processing / Food Packaging TRN - Transport (Air, Water or Land)
FIN - Financial Services UTI - Utilities (Electricity, Gas & Water Supply)
FXD - FX Dealer / Money Changer WAT - Collection, Purification and Distribution of Water
GAC - Gaming Clubs / Casino OTH - Others
GOV - Government Service – NP
A – Allowance D – Donations/Contributions & the like P – Pension O – Others, please specify
Source of
B – Business F – Campaign Funds R – Remittance
Funds*** C – Commission I – Interest on Savings/Placements/Investments S – Salary
.

Member: PDIC. Maximum Deposit Insurance for Each Depositor: Php500,000 071417