AGENCY APPLICATION/INFORMATION SHEET

(AIS v.1.2) 2013 form

Universal Storefront Services Corporations Application Date:

711 EDSA corner New York Street, Cubao, Quezon City, 1109, Philippines

Registered Business Name :

Business Address :
Business Office number: Mobile Phone Number:
Business Website: Email Address:

Type of Business : Single Proprietorship: Partnership: Corporation: Cooperative: Others:

Nature of Business: Years in Business:
SEC Registration No. : Business Permit No.: DTI Reg. No.:
Authorized Capital : Paid-up Capital :

HOME DETAILS
Permanent/Home Address:
Present Address:
Home Phone Number:
Residence Type:
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Living w/ Parents: Owned: Renting: Mortgaged: Others: _________________

ABOUT YOURSELF
Name: ______________________________________ Maiden Name (if Married): _____________________________________________
TIN No.: ______________________________________ Date of Birth: _____________________________________________
SSS No.: ______________________________________ Place of Birth: _____________________________________________
GSIS No.: ______________________________________ Nationality: _____________________________________________
Educational Attainment: _____________________________________________________________________________________________
Marital Status: ________________________
College Degree: Gender:
Last School Attended: Male
Female

PERSONAL REFERENCE (not living with you)

Name Address Contact Number Relationship

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OFFICERS AND/OR DIRECTORS

Name Designation

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BANK REFERENCES
Bank Name/Branch Tel. No. Account Type & No. Bank Signatories (Print & Sign)

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CREDIT REFERENCES
Company Credit Term/Line Tel No. Contact Person

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OTHER BUSINESS INFORMATION

Contact Persons (Name/Designation): Contact #: __________________

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Other Services Offered: _____________________________________________________________________________________________

BILLING INFORMATION

Billing Address : _____________________________________________________________________________________________

Contact Person (Name/Designation) : _________________________________________ Contact No.: __________________

Required Documents to Support this Application Form

For Single Proprietorship (cont. of requirements for Partnership/Corporation)
* DTI Certificate of Registration * SEC Certificate of Registration
* Latest 2-year ITR/Audited Financial Statement * Board of Resolution (for Corporation) or Special Power of Attorney
* Passport Size Picture (for Partnership) authorizing the following inviduals:
* List of Branches with addresses and contact numbers * Officers/Employees authorized to apply for credit line.
* Company Profile * Officers/Employees authorized to coordinate with USSC
* List of present stockholders stating the subscribed stock and
For Partnership/Corporation paid in capital duly notarized or certified by the Corpoate Secreetary.
* DTI Certificate of Registration * Latest 2-year audited Financial Statements
* Articles of Incorporation & By-Laws (for Corporation) * List of Branches with addresses and contact numbers
or Articles of Partnership (for Partnership) * Corporate Write-up/Company Profile

I/We hereby certify that the foregoing information are true and correct and hereby authorizes USSC to obtain pertinent credit information from
banks, credit card companies, private and government financial and other institutions in the course of credit investigation, and hereby authorizes
the release of such information by the bank, credit card company, financial and other institution from whom credit information is being requested.

Signature over Printed Name Date