Form Code: BLPAP2017-1

Effectivity Date: 07-09-2021

Revision: 5

APPLICATION FORM
CUSTOMER IDENTIFICATION NO.: DATE OF
(to be filled out and assigned by the company) APPLICATION:

The companies (CLARC FEEDMILL INC. and LUCKY 4A CORPORATION) are collecting the following personal information for reasonable
business purposes and to meet the purposes for which you will submit the information, such as determining your qualifications and capacity to be
part of the company’s BeneFEED Loyalty Program. We will not disclose your personal information to third parties except when required by law or
when we have your consent or deemed consent. You do consent for us to disclose your personal information to any legal counsel or proceeding,
should such be made necessary by your breach of any agreement with the company and/or your failure to pay any amount that may be due to the
company.
With my consent:

_________________________
(Signature Over Printed Name)

* Please fill out this form completely and correctly.

PERSONAL INFORMATION
LAST NAME FIRST NAME NAME MIDDLE NAME
EXTENSION
( eg. Jr., II )
NAME OF
CUSTOMER
MOTHER’S
MAIDEN NAME
(Pangalan ng Ina sa
Pagkadalaga)
NAME OF SPOUSE
(If married)
PLACE OF BIRTH (City/Municipality, Province) NATIONALITY

DATE OF BIRTH
M M D D Y Y Y Y

SEX CIVIL STATUS OCCUPATION: ID PRESENTED:

Male Single
Female Married ______________________________________ _____________________________________
CONTACT NO.(S): ID NUMBER:
Widow/er

ADDRESS:

NAME OF STORE WHERE FEEDS ARE BOUGHT:

(Pangalan ng Tindahang Binibilhan ng Feeds)

BUSINESS INFORMATION:
Please indicate the NUMBER OF ANIMALS REARED: DATE STARTED USING OUR
PRODUCTS: (ILAGAY ang BILANG NG INAALAGAANG HAYOP):
M M Y Y Y Y
Sow Boar Suckling Weaner Starter Grower Finisher Broiler Rabbit Rabbit
(Inahin) (Barako) (sumususong biik) (Walay) (DOE) (BUCK)

FEEDS BRANDS USED: Conformed by:

Lucky 4A Miller I hereby certify that all the above information given are true and correct.
Healthyway Feed Tech Series
Cowbayo __________________________________
Costmo Signature Over Printed Name / Date

For BLP DEPARTMENT

Mode of Redemption: BeneFEED eCoupon App Received by: Validated by: Enrolled by:
Registered:
Date: Date: Date:

created by:
 Form Code: BLPAP2017-1
Effectivity Date: 07-09-2021
Revision: 5

APPLICATION FORM

created by: