Customer Information Form Individual

Branch Code 626 Branch NameDavao-Abreeza Type of AccountEmployment Date August 19, 2000 RM/Customer
Number

I. MANDATORY INFORMATION
1. Name
IKENE JOY MAY CLARIT
BURDAS
Last Name First Name Middle Name Suffix (Jr., III) Other Name/AKA
2.a. Date of Birth (mm/dd/yyyy) 2.b. Place of Birth 3. With Beneficial Owner/Agent?
05 – 13 – 2000 TAGO, SURIGAO DEL SUR PHILIPPINES Yes (Fill-out Part III. Beneficial Owner/ None
City/Municipality Country Agent Information)
4. Present Address
CAMIA UBALDE DAVAO DAVAO DEL SUR PHILIPPINES
8000
House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code

5. Permanent Address (if not same as present address)

LAURENTE PURISIMA TAGO SURIGAO DEL SUR PHILIPPINES
8302
House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code
6.a. Mobile Number 09485572238 Residence Phone
6.b. 6.c. Email Address
Number [email protected]
Yes No
Enroll in Mobile Banking? Yes No Yes No Enroll in MetrobankDirect-Online?
Enroll in Metrophone Banking? Preferred User Name:
7. Nationality Nature of
8.a. 8.b. Name of Employer/Business a.
FILIPINO Employment/Business BPO COMPANY b.
c.
9. Source/s of Funds (Please check ALL that apply) 10.a. TIN 10.b.SSS/GSIS/UMID
Salary/Employment Pension Others (Please specify) No. 0945792525
Business Remittances (Please specify country of origin) Reason for no TIN/SSS/GSIS/UMID No.
Commissions

II. CLIENT PROFILING

11. Civil Status 12. Spouse's Name (Last, First, Middle) 13. Mother's Maiden Name (Last, First, Middle)
Unmarried Widowed CLARIT, JOEY CALIT
Married Divorced/Annulled 14. Gender 15. Type of ID Presented 16. ID Number
Separated Male Female PHILHEALTH 16-025841006-5
17. Purpose of Account Opening 18. No. of Dependents 19. No. of Children
Savings Pension
Business Remittance (Please specify country) Others (Please specify) 20.Monthly Bank Statement for
Payroll Origin Destination Pick-Up
(For Checking Account only)
Yes No
21. U.S. Address (if applicable) House/Floor No., Street, City, State, Postal Code 22. U.S. TIN

23.a. Employer/Business Address House/Floor No., Building Name, Street, Subdivision, Barangay, Municipality/City, Province, 23.b. Employer/Business Contact
District, Country, Zip Code No.

24. Job Title/Position

Top/Senior Management Rank and File/Clerical Overseas Filipino Worker Self-employed Others (Please specify)
Manager/Middle Mgt Professional/Consultant Government Employee Student
25. Expected Frequency of Transaction per Month 27.Preferred Mailing
(deposits, withdrawals, etc)
26. Average Amount per Transaction
Address
Below P50K P51K to P100K
5x 10x Permanent
P101K to P500K P501K and
Address Present
15x Others (Please specify) above
Address

28. Types of Products and Services to be availed from the Bank (Please check ALL that apply)
Regular Savings Deposit (Passbook-Based)/ATM Savings Deposit/ Current/Checking Account
Savings Payroll Account/Prepaid/Debit Card Accounts Auto Credit/Debit/Pension
For Debit/Prepaid Card, ACTIVATE International Transactions? Inward Remittance (specify country of origin)
Yes No Outward Remittance (specify country of destination)
Time Deposit/Trust or Treasury Products Others (Please specify)
29. Do you hold a prominent public position in the Philippines/a Foreign State/an International Yes Government Office
Position No Organization?
30. Does your spouse/partner/ child/child’s spouse/parent/parent-in-law hold prominent public Name of Relative
Yes
Gov't Office & Position position in the Philippines/a Foreign State/an
No
International Organization?

31. Are you a Close Associate of a person who holds a prominent public position in the Yes Name of Official Gov't Office & Position
No Philippines/a Foreign State/an International Organization?

III. BENEFICIAL OWNER/AGENT INFORMATION (If any) (Use separate sheet, if needed)
1Beneficial Owner (e.g., TITF, ITF)Agent (e.g., Attorney-in-Fact) RM/Customer Number
Last Name First Name Middle Name Suffix (Jr., III)

Date of Birth (mm/dd/yyyy) Nature of Employment/Business Nationality

Place of Birth
--
City/Municipality Country
Present Address

House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code
Source/s of Funds (Please check ALL that apply)
Salary/Employment Commissions Remittances (Please specify country of origin) Others (Please specify)
Business Pension
MB-I-M-217/ Nov'18
2 Beneficial Owner (e.g., TITF, ITF) Agent (e.g., Attorney-in-Fact) RM/Customer Number

Last Name First Name Middle Name Suffix (Jr., III)

Date of Birth (mm/dd/yyyy) Place of Birth Nature of Employment/Business Nationality

- - City/Municipality Country
Money Changer (MNC)
Present Address

House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code
Source/s of Funds (Please check ALL that apply)
Salary/Employment Commissions Remittances (Please specify country of Others (Please
origin) specify)
Business Pension

DEPOSIT ACCOUNT
By signing below, I/we confirm that I/we have received and read the Deposit Terms and Conditions governing this account and have fully
understood and agreed to be governed by the provisions thereof, including but not limited to, the provision on my/our obligations as a depositor
should the Bank opt to purchase my/our checks; the survivorship agreement authorizing the Bank to release the balance of an "OR" account to
the surviving co-depositor in the event of the death of one depositor; the conditions under which the Bank is given the right to impose service
charges, freeze, debit and/or automatically close the account; the provision where I/we authorize the Bank and its subsidiary/affiliate to
share/disclose information/data pertaining to me/us; the provisions on electronic, internet, and telephone banking services and any other
banking products and services; and the provision on the authority of the Bank to withhold and set off my/our bank deposit for any and all
obligations with the Bank and any of its subsidiaries and affiliates.

I/We fully understand the corresponding risks involved in availing of any banking products, facilities, or services. Further, my/our continued
use and/or availment of the banking products, facilities, or services shall mean my/our conformity to any and all supplement(s), modification(s)
or amendment(s) of such Terms and Conditions which may be posted in conspicuous places within the Bank's premises or which may be
published in any other manner.

I/We also warrant that I/we am/are aware of the provisions of Republic Act No. 9160 (Anti-Money Laundering Act of 2001) as amended, and
I/we represent that my/our transactions herein are not among those covered under the said law and that all funds to be deposited in the
account(s) come from my/our legitimate undertakings. I/We authorize the Bank to make any such verifications or reports in compliance with RA
No. 9160, as amended, as it may deem appropriate, for which acts I/we hold the Bank free and harmless from any and all liabilities, claims
and/or damages.

I/We also attest to the truth and correctness of my/our given personal/business information. In case I/we apply for any credit accommodation,
I/we hereby authorize the Bank and its officers and staff to obtain and disclose information on my/our deposits and other properties whether
within Metrobank or with other banks.

In compliance with the BSP Manual of Regulations for Banks, please be advised that your account may be selected in the regular generation of
Confirmation Letters by our Audit Group to confirm account balances. The Confirmation Letter will be sent directly to your ‘mailing address’.

IKENE JOY MAY C. BURDAS 08-19-2022

Customer's Signature over Printed Name Dat
e

By ticking this box, I/we hereby authorize Metrobank to share my DATA PRIVACY
personal AGREEMENT
information and/or sensitive personal information, and deposit details pertaining to this
Account in order for the Bank, its affiliates and/or subsidiaries within the Metrobank Group to offer or to provide other related products and services to the Depositor,
including but not limited to cross-referencing, cross-selling, status inquiry, and providing credit opinion and evaluation. I may revoke the authorizations at any time by
notifying in writing my branch of account or by sending an email to [email protected]

IKENE JOY MAY C. BURDAS 08-19-2022

Customer's Signature over Printed Name Dat
e

TO BE FILLED-OUT BY THE BANK

Documents/Information to be obtained:
Supporting information on the intended Nature of Deed of Loan Application
Business Relationship/Source of Funds/Source of Donation Others (Please
Wealth Deed of Sale specify)
Reason for intended or performed transaction Other reasons (Please specify) None

List of companies where he is a Stockholder, Company Name/s Position None

Director, Officer, or Authorized Signatory

Other relevant information available through public

List of Banks where the individual has maintained Bank Name/s None
or is maintaining an account

DECLARATION AND ACKNOWLEDGEMENT

I declare that the face-to-face conduct of KYC as Reviewed Account Opening Documents and Signature Approved by (for High Risk)
prescribed by BSP has been performed. Authenticated by

SIGNATURE OVER PRINTED SIGNATURE OVER PRINTED NAME BRANCH

NAME OF OF BANK OFFICER HEAD
BANK OFFICER