Philippine College of Optometrists

Name

II.

Address

III.

Type of Organization

Single Proprietorship
Partnership
Corporation
Others

IV.

Management and Ownership

Name of Principal

% of Ownership

Position & Function

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Company History

VI.

Banking and Other Relevant Financial Information

VII.

Equipment Details

a. Unit / Model

b. Supplier / Vendor

Tel. No.

Fax No.

c. Net Price

b. Supplier / Vendor

VIII.

Operations

a. Products / Services
(if highly specialized/not common, please provide short description)

b. Facilities

c. Manpower Complement

d. Supplier and Trade References

Supplier Name

Contact Person

Contact Number

Credit Terms

e. Competitors

Competitor's Name

Brand

Product

Market Share

Other Significant Information that will Assist in your Account's Evaluation

Statement of Assets and Liabilities

a. Assets DEPOSITS
Bank	Deposit Type	Amount
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REAL PROPERTY
Address	Lot Area	Est. Value/Sq.M.
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VEHICLES
Vehicle Make and Model		Value
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STOCKS
Company / Issue Symbol		No. of Shares
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b. Liabilities

Bank

Type of Loan

Amount of Loan Line

Outstanding Balance

Borrower's Name

Spouse / Co-Maker's Name

I/We affirm that the statements made in this application and the information given by me/us are true and correct and that any material misrepresentations or falsity therein will be construed as an act to defraud BPI Leasing Corporation/BPI Rental Corporation for which civil and/criminal liability can be pursued agains me/us. I/We agree to notify BPI Leasing Corporation/BPI Rental Corporation of any material change affecting the statements/information mentioned herein. I/We Authorize you to verify and investigate such statements/information as may be required from above references or from whatever other sources you may consider appropriate, inlcuding the Bureau of Internal Revenue (the "BIR") in order to establish the authenticity of my/our Income Tax Return ("ITR") and the accompanying financial statements which I/We submitted in connection with our loan/credit application/accomodation with the BPI Leasing Corporation/BPI Rental Corporation. Further, I/We hereby authorize the BIR to give copies of my/our ITR and financial statements and/or disclose any information to the BPI Leasing Corporation/BPI Rental Corporation relevant to the said verification. For this purpose, I/We hereby waive my/our rights on the confidentiality of client information. I/We agree that all statements/information obtained by BPI Leasing Corporation/BPI Rental Corporation shall remain your property whether or not the loan/lease is granted. I/We agree that all statements/information gathered about me/us will be used to determine my/our eligibility for this loan/lease.