LAST NAME FIRST NAME MIDDLE NAME AGE CIVIL GENDER MOBILE NO.

STATUS Male [ ]
Female [ ]
C
PRESENT ADDRESS (ei., House #, Street, Brgy, City/Municipality,Province) ZIP DATE OF BIRTHPLACE NATIONALITY
O CODE BIRTH
M
A PROVINCIAL ADDRESS (ei., House #, Street, Brgy, City/Municipality,Province) ZIP GSIS NO. TIN
CODE
K
E
SCHOOL NAME & ADDRESS REGION DIVISION STATION EMPLOYEE
R CODE CODE CODE NUMBER

In connection with my loan application, I hereby acknowledge and authorize:

1.) the regular submission and disclosure of my basic credit data ( as defined under Republic Act No.9510 and its
implementing Rules and Regulations) to the Credit Information Corporation(CIC), as well as any updates or
corrections thereof; and
2.) the sharing of basic credit data with other lenders authorized by the CIC, and credit reporting agencies duly
accredited by CIC

AGREEMENT:

I/We affirm that each statement made in this application is true and correct, and agree to notify the bank
of any material change affecting the information contained herein I understand that any false or misleading
information that I may provide the bank which may lead to any loss or damage to the bank maybe used against
me. I/We authorized you to obtain and verify such information as may be required covering this application. You
may approve or reject my/our application at you sole discretion. I/We understand that should my/our application
be denied. AMA Rural Bank has no obligation on its part to furnish the reason on such rejection. Furthermore,
I/We agree that information obtained by AMA Rural Bank shall remain its property whether or not the loan is
granted.

BORROWER:_______________________ CO-MAKER:__________________________
(Signature over Printed Name) (Signature over Printed Name)

Signed in the presence of ( for AMABank use only)

_______________________ __________________________
(Signature over Printed Name) (Signature over Printed Name)