CUSTOMER INFOMATION SHEET
Contact us : 0919 080 8453
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Appliance
Cellphones/Laptops/Computer
Furnitures
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Bajaj
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3 Months
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3 Months
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3 Months
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36 Months
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3 Months
6 Months
9 Months
12 Months
18 Months
25 Months
36 Months
48 Months
Model
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Bajaj RE
Maxima
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Unit Model (ex. Samsung TV 32" )
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C U S T O M E R I N F O R M A T I O N
Salutation
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Mr.
Ms.
Mrs
Phone Number
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Full Name
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First Name
Middle Name
Last Name
Birthday
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
E-mail
example@example.com
Present Address
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Complete Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permanent address same as present? (Y/N)
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Yes
No
Permanent Address
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Complete Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Status
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Single
Married
Mother's Maiden Name
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First Name
Last Name
Middle Name
Father's Name
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First Name
Last Name
Middle Name
Spouse Name
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First Name
Last Name
Middle Name
Dependent 1. Type N/A if none.
*
Dependent 2. Type N/A if none.
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Dependent 3. Type N/A if none.
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R E F E R E N C E S
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First Name
Last Name
Address (ex. Gusa CDO )
Contact no.
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First Name
Last Name
Address (ex. Gusa CDO )
Contact no.
I N C O M E I N F O R M A T I O N
Source of Income
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Employment
Business
Remittance
Self Employed
Company name
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Designation
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Date hired
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Name of Business
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Business Address
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Remittance from ( Name and Relation)
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Country
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Remittance amount every month
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Self Employed
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Gross Income
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Years of Business
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Proof of income
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Pay slip or Business Permit or DTI or BRGY cert. Remittance Slip. Or any form of proof of income
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Home address Sketch
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Any valid ID ( Drivers license if applyin for motorcyle
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