Mobility Service Application Form for

Solutions Corporate Managed Accounts

Company Information

1 COMPANY NAME
4 AUTHORIZED CORPORATE/OFFICER SIGNATORY 1
POSITION IN COMPANY CONTACT NO.

2 REGISTERED BUSINESS ADDRESS (Unit/Floor/Building Name/Street No./Street Name) E-MAIL ADDRESS

BARANGAY/MUNICIPALITY/TOWN AUTHORIZED CORPORATE/OFFICER SIGNATORY 2

POSITION IN COMPANY CONTACT NO.

CITY/PROVINCE POSTAL CODE/ZIP CODE

E-MAIL ADDRESS

NOTE: Business address must be the company's business address. It is within the
AFTER-SALES CORPORATE SIGNATORY 1
Philippine soil and not addressed to any P.O. box.
5 POSITION IN COMPANY CONTACT NO.

3 INDUSTRY
E-MAIL ADDRESS
MANUFACTURING FOOD POWER AND UTILITIES
MANUFACTURING NON-FOOD PETROLEUM
SEMICON IT AFTER-SALES CORPORATE SIGNATORY 2
DISTRIBUTION MEDIA POSITION IN COMPANY CONTACT NO.

LOGISTICS AND TRANSPORT FINANCIAL INSTITUTION

E-MAIL ADDRESS
EDUCATION REAL ESTATE AND CONSTRUCTION
RETAIL BPO
HEALTHCARE SERVICES HOSPITALITY 6 VAT TAX EXEMPTION
VAT OCT
GOVERNMENT
✔ YES Attach BIR Certificate/Sample YES Attach BIR Certificate/Sample
OTHERS (Please specify) ____________________________________________ Account No. Account No.
NO NO

TIN / SEC REGISTRATION

Billing Instructions
7 DETAILED BILLING STATEMENT 8 BILL SUMMARY
How would you like to receive your detailed billing statement? Would you like to receive a bill summary?
YES NO
SOFT COPY (email to this address)

If yes, how would you like the bill summary?

SOFT COPY (email to this address)

HARD COPY (send to this preferred billing address)
ATTENTION:
First Name
HARD COPY (send to this preferred billing address)
Last Name ATTENTION:
First Name

DEPARTMENT
Last Name

ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

DEPARTMENT

BARANGAY/MUNICIPALITY/TOWN
ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

CITY/PROVINCE POSTAL CODE/ZIP CODE

BARANGAY/MUNICIPALITY/TOWN

CITY/PROVINCE POSTAL CODE/ZIP CODE

BY SUBMITTING THIS FORM, I CERTIFY THAT ALL THE ABOVE INFORMATION IS ACCURATE, AND I AGREE TO THE TERMS AND CONDITIONS OF THIS SERVICE.
Subscriber's Declaration For Globe Telecom's Use Only
I/We hereby confirm that the foregoing information is true and correct, I have checked and verified the supporting credit requirements against the
and that the supporting documents attached hereto are genuine and original documents and found them to be authentic and in accordance in
authentic and voluntarily submitted by the subscriber for the purpose of accordance with GLOBE TELECOM requirements.
an application for a Globe mobile service.
ACCOUNT MANAGER NAME/ID
I/We the authorized representative/s of the company hereby authorize
GLOBE TELECOM to obtain pertinent credit information from banks,
credit card companies, and other financial institution on the course DATE SIGNATURE
of credit investigation of the company's application, and I/We hereby
authorize the release of such information by the bank, credit card, and CORPORATE CODE
financial institutions from which credit information is requested.

I/We hereby confirm that I/We have read and understood the Terms and CORPORATEID NUMBER
Conditions stated on the reverse side of this form and that the company
shall comply with them and with any additional terms and conditions in YES (Please indicate number)
any certificate required to be executed in connection with any particular
NO
GLOBE TELECOM promotions or plans.

I/We acknowledge and agree to the minimum subscription period to the VPN SUBSCRIBER?
relevant Service availed of. If I choose to downgrade my plan, transfer YES (Please indicate number)
any rights or obligations of my subscription or terminate or cancel my
subscription within the minimum subscription period then I agree to pay NO
the relevant fees and penalties.
ASSIGNEE LIST NUMBER
I/We am aware of the fees, rates and charges relevant to the
Service availed of and I agree to pay the same within the due dates.
I understand that I will be subject to interest and penalties for REMARKS
late payment or non-payment stated in the Terms and Conditio
ns. MOBILE NUMBER ACCOUNT NUMBER
I/We agree that this Subscription Agreement shall govern our relationship
for the service currently availed of and service I will avail of in the future.
CUSTOMER CLASS ACCOUNT CATEGORY
I/We consent to the company’s disclosure of information concerning
myself/ourselves or my/our subscription to financial institutions, credit
CREDIT CHECKED/DATE
bureaus or similar organizations.

I/We hereby confirm that any device issued by GLOBE TELECOM is my full APPROVED/DATE
responsibility. The damage to or loss of device is not a valid ground not
to pay the MSF and other charges. GLOBE TELECOM has no obligation to
ACTIVATED/DATE
repair or replace a damaged device outside the manufacturer’s warranty.

For Corporate Managed

AUTHORIZED SIGNATORY (Signature over printed name)

__________________________________________________________________________________________________________________________

DATE

__________________________________________________________________________________________________________________________

Checklist
AUTHORIZED SIGNATORY (Signature over printed name)

For existing accounts:

__________________________________________________________________________________________________________________________
SIGNED MSA
DATE
ASSIGNEE LIST

__________________________________________________________________________________________________________________________
For new accounts:

SIGNED MSA

ASSIGNEE LIST

BUSINESS REGISTRATION DOCUMENTS ( i.e. SEC REGISTRATION)

ID OF AUTHORIZED SIGNATORY

SECRETARY'S CERTIFICATE TO AUTHORIZE THE COMPANY SIGNATORY

FINANCIAL STATEMENTS

PROOF OF BILLING ADDRESS