ECASH CENTER APPLICATION FORM

APPLICATION TYPE:

New Affiliation

System Upgrade

Change of Ownership

PERSONAL DETAILS
TITLE: { } MR
{ } MRS
{ } MS
NAME: _____________________________________________________________________________
(Last Name)

(First Name)

(Middle Name)

MOTHERS FULL MAIDEN NAME: ________________________________________________________________________________________

(Last Name)

(First Name)

(Middle Name)

PERMANENT ADDRESS: _______________________________________________________________

(Room/Floor/Bldg Name/No./Street)

(Municipality/Town/Barangay)

___________________________________________________________________________________
(City/Province)

(Zip Code)

TELEPHONE NUMBER/S: ________________ CELLPHONE NUMBER: _______________________

EMAIL ADDRESSES: (Pls. indicate your official E-mail address)
_________________________________________________
DATE OF BIRTH: ___________
PLACE OF BIRTH: _______________ CITIZESHIP: _____________
(MM/DD/YYYY)

GENDER:
MALE
FEMALE
CIVIL STATUS:
SINGLE
MARRIED
WIDOW/WIDOWER LEGALLY SEPARATED
SPOUSE NAME (If Applicable): _________________________________________________________
(Last Name)

DATE OF BIRTH (SPOUSE): _____________

(First Name)

(Middle Name)

NUMBER OF CHILDREN: __________

(MM/DD/YYYY)

CITIZENSHIP: _______________________
PROFESSION OF SPOUSE/COMPANY NAME: ________________________________________________
POSITION: _______________________ SPOUSE CONTACT NUMBER: _________________________

OUTLET/FINANCIAL INFORMATION
BUSINESS NAME: ___________________________________________________________________
BUSINESS TYPE:
SINGLE PROP.
PARTNERSHIP
CORPORATION
COMPLETE BUSINESS ADDRESS: __________________________________________________________
(Room/Floor/Bldg. Name/No./Street)

(Municipality/Town/Barangay)

___________________________________________________________________________________
(City/Province)

(Zip Code)

TAX IDENTIFICATION NUMBER (TIN):

OFFI
OFFICE TELEPHONE NUMBER: _______________
CURRENT POSITION HELD: ____________________

YEARS OF THE COMPANY: ________________

AUTHORIZED CONTACT PERSON IN YOUR ABSENCE (If applicable):

______________________________________________________________________________________
(Last Name)

(First Name)

(Middle Name)

RELATION: _________________
CONTACT NUMBER: _____________________
EMAIL ADDRESS (Pls. indicate your official E-mail address): ____________________________________
AUTHORIZED SIGNATORIES:
1.) ______________________________________________________________________________
(Last Name)

(First Name)

(Middle Name)

2.) ______________________________________________________________________________
(Last Name)

(First Name)

(Middle Name)

COMMUNITY TAX CERTIFICATE NO.: ____________________

ISSUED AT: ___________________
ISSUED ON: ______________________

DECLARATION
1. I hereby confirm that the foregoing information is true and correct, and that supporting
documents attached hereto are genuine and authentic and voluntarily submitted by me for the
purpose of my application to the Facility.
2. I consent to the companys disclosure of information concerning myself/ourselves or my/our
subscription to financial institutions, or similar organizations.
3. I hereby authorize (UNIFIED PRODUCTS AND SERVICES) to use my personal information for
communication related to my subscription, to any new products and services offered by you or to
any products and services offered by third parties.
4. I hereby authorized (UNIFIED PRODUCTS AND SERVICES) to send me SMS alerts pertaining to your
(UNIFIED PRODUCTS AND SERVICES) promos and services.
5. I am aware of the fees, rates and charges relevant to the Facility availed of.
6. I agree that this Subscription Agreement shall govern our relationship for the service currently
availed of and facility will avail of in the future.

__________________
Merchants Signature
(over printed name)

_____________
Date

RECOMMENDATION/ENDORESMENT
ENDORSED BY (DEALER)

Date Recvd by
In-House

REGCODE NUMBER

FOR UPS USE ONLY

Checked/Reviewed by:
Affiliation Approved by:
(Dept Head)

ADDRESS:

Account ID:

SPECIAL INSTRUCTIONS/RECOMMENDATIONS:
______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

ECCAPF-01 REV 04282014/JFS