APDS LOAN APPLICATION / AGREEMENT Said data may be collected, processed, stored,

NEW RENEWAL CODE: I agree that this loan application shall be subject
I hereby apply for a loan in the amount of PESOS updated, or disclosed by any member of the to the Bangko Sentral ng Pilipinas’ regulations,
DATE: CSBI Group and CSBI’s accredited insurers and including those pertaining to directors. Officers,
(Php ) for the specific purpose of shared between and among them or to third stockholders and related interests of the Bank.
CLIENT INFORMATION parties (i) for legitimate purposes including but
Name (Last Name, First Name, Middle Name) for a term of months, which I promise to not limited to credit and risk management, I further agree and understand that, should this
pay in accordance to the rules and regulations of know your customer (KYC) checks, prevention application be denied, the Bank is not obligated
CITYSTATE SAVINGS BANK INC. and the terms and detection of fraud or crime, system or to furnish the reason for denial.
Division Code: Station Code:
and conditions as stipulated in the covering product development and planning, cross-
Employee #: Promissory Note that have been fully disclosed selling, direct marketing, profiling, complaints Further I understand that I may access, update,
Nature of Work: and explained to me and which I certify to have management, insurance, audit and or correct certain personal information, or
Nationality: Civil Status: understood clearly. administrative purposes, and relationship withdraw consent to the use of any of my
TIN#: GSIS #: management, (ii) to provide services to me or information as set out in this letter at any given
DATA PRIVACY ACT CONSENT FORM implement transactions which I request, allow,
Gender: Male Female Age: time by communicating with the CSBI Data
I hereby certify that all information or authorize, and, (iii) to comply with CSBI Protection Officer at 2/F Citystate Centre, 709
Mother ‘s Maiden Name: provided here in this application and in all Group’s internal policies and CSBI Group’s Shaw Booulevard, Pasig with contact numbers
Date of Birth: supporting documents are true and correct. reporting obligations to comply with (a) 8706-5864 and at dpo@citystatesavings.com. I
Place of Birth: I voluntarily grant consent to Citystate Applicable Law, and internal policies or recognize that I may file complaints with and/or
Present Address: procedures, or (b) any demand and/or requests seek assistance from the National Privacy
Savings Bank Inc.,(CSBI) and its authorized
from Government Authorities for purposes of Commission.
Zip Code: representatives to verify any and all
reporting, regulatory trade reporting, disclosure
Permanent Address: information as may be required, from or other obligations under Applicable Law. I hereby acknowledge that this record
Zip Code: whatever source/s that the bank may
supplements but does not supersede nor replace
Source of Funds: consider appropriate. I fully understand I hereby authorize and give consent to members
any other consent I may have previously
Gross Annual Income: that any misrepresentation or falsity herein of the CSBI Group and CSBI accredited insurers
provided to CSBI or any of its accredited
shall be construed as an act to defraud CSBI to process, collect, use, store, or disclose my
Name of School/Employer: insurers. This form is to be construed in
information between them and to other
that may cause the disapproval of my accordance with Philippine Law.
members, to Governmental Authorities, and to
Address of School/Employer: application, or subject me to civil and
third parties, as may be necessary.
criminal liabilities. I am also voluntarily
giving my consent on the general use and My information may continue to be collected,
Position: Borrower’s Signature Over Printed Name / Date
sharing of information obtained from me in stored, processed and/or shared between and
Employment Status:
the course of my Application, between me among members of the CSBI Group and CSBI
Witness:
Office Telephone #: accredited insurers for five (5) years from the
and Citystate Savings Inc., (CSBI), its related
Mobile #: companies and affiliates and their conclusion of my Transactions with them and
Residence Telephone #: respective representatives and agents
any of their members or until the expiration of
Signature Over Printed Name / Date
Email Address: the retention limits set by Applicable Law,
and/or any of CSBI’s accredited insurers or whichever comes later. FOR BANK’S USE ONLY
Facebook Account: from third parties. I understand and agree
SPOUSE INFORMATION Signature Verified by:
that any member of the CSBI’s related I do understand that CSBI and its accredited
Name of Spouse: Application Received by:
companies and its accredited insurers may insurers are committed to ensuring the
Date Received:
Age: Contact #: share these data between them and such confidentiality of my information under
Republic Act No. 1405 or the “Bank Secrecy We recommend a loan of Php
Name of Employer: data may constitute my personal or
Law”, Republic Act No.8791 or the “General be granted for a period of Months
Occupation: sensitive personal information as defined
Banking Law of 2000”, and Republic Act No. 6426 Name of Borrower:
Gross Annual Income: under the Data Privacy Act, as well as or “The Foreign Currency Deposit Act” subject to Date of Booking:
information relating to my accounts,
Date of Birth: Applicable Law, and will exert reasonable Referred by:
transactions and communications with any efforts to protect against unauthorized use or
Business Address: Apporver(s):
member of the related companies. disclosure.