ECOLOGY

S P E C I A L I S T , I N C.

BLDG. F. PHOENIX SUN BUSINESS PARK, E. RODRIGUEZ

JR. AVENUE, BAGUMBAYAN, QUEZON CITY
TIN NO.: 201-219-690-000

Dealer/Operator's Name:
Branch:
Address:

CUSTOMER INFORMATION SHEET

Please answer all question with complete and accurate information, incomplete and partial answers will delay the
processing. All Information is confidential and will be held in strict confidence for the usage of our Credit Department.

Business Name:
Business Address:
Business Telephone No.: Fax No.:
Nature of Business: Date Established:
SEC/DTI Registration No.: Date Registered:
Type of Organization: Single Proprietorship Partnership Corporation Others
Tax Identification No.: VAT Registered: Non-VAT Registered:

Company Key Officers, if corporation/partnership:

Name Position Contact Number

Plant/Warehouse/Branch/Building used in actual operations: Location

List of five (5) major suppliers:

Name of Supplier Product Address Contact Person & Tel. No.
Bank References:
Name of Bank/Branch Account No. Existing Credit Line Contact Person & Tel. No.

Authorized Check Signatories:

Name Position Specimen Signature

Please submit xerox copies of the following documents:

1. SEC/DTI Certificate
2. Current Business Permit
3. Income Tax Return/Audited Financial Statement (of the past 2 years)
4. Bank Statement for the last two (2) months
5. BIR Certificate of Registration
6. Company Profile

I hereby certify that the above information are true and correct to the best of my knowledge. Further, hereby

Certified By:

Printed Name and Signature

Position:
Date:

AUTHORIZATION:

The client authorizes ECOLOGY SPECIALIST, INC. to make inquiries on Suppliers/Traders and Bank Account.

CONFORME: