HSBCS I-POD TOUCH PROMO APPLICATION FORM ONLY APPLICATIONS WITH COMPLETE INFORMATION AND DOCUMENTS WILL BE PROCESSED

APPLICANT INFORMATION ( Please write in block letters only ) Type X for selection, example ( X ) and Type the Information Needed in the Boxes. I want to apply for : Master Card Classic ( X ) Visa Classic ( ) Red MasterCard ( females only ) ( ) Mabuhay Miles Visa Classic ( First Name Middle Name Last Name DENNIS GAMOS CAYABYAB Mothers Maiden Name: ( First, Middle, Maiden Surname ) LUZMARIE FUELLAS GAMOS Name to appear on card ( max of 19 characters ) DENNIS G. CAYABYAB Date of Birth: ( dd/mm/yy ): Place of Birth: 14/02/84 QUEZON CITY Marital Status: (X ) Single ( ) Married ( ) Widowed ( ) Divorced/Separated ( ) Living Together SEX: ( X ) Male ( ) Female No. of Dependents: ( 0 ) SSS No. : Tax ID No. ( TIN ) : 33-9861667-9 254-335-273 Current Home Address (No., Street, Subdivision/District, Municipality/City ) : 90-D 14TH AVE., VILLALUNA BLDG., MURPHY, CUBAO, QUEZON CITY Postal Zip Code: Home phone no. ( area code + no. ) : Email Address : Dennis.cayabyab@yahoo.com Residence Type : ( ) Renting ( X ) Living with parents/relatives Length of stay in present address Do you own a car? Yes or No? NO YOUR PERSONAL REFERENCE ( person not living with you ) (First Name, Middle Name, Last Name ) Mobile phone no. ( mobile code + no. ) : 0906-3213140 )

) ( ) ( 8 )yrs

Loan/Mortgaged property Fully-owned ( ) mos

Name GLENDA CUNTAPAY Relationship COLLEAGUE Home Address (no.)

( street )

( subdivision)

( municipality ) Fax no. ( area code + no. ):

Home or Office phone no. ( area code + no. ) : 0928-2879098

YOUR OCCUPATION AND FINANCES Employer / Business Name: Department: TWINFORCE SECURITY TRAINING ACADEMY, INC. CORPORATE OFFICE Office Address - ( Floor, Bldg Name, Bldg no., Street, Municipality/City ) PO Box is NOT acceptable UNIT 307 VICAR BLDG., 25 DENVER COR. NEW YORK ST., CUBAO , QUEZON CITY

Office phone no. ( area code + no. ) : 02-7219280 Job Title : MANAGER Business Type: ( X ) Private corporation/business ( ( )

Nature of Business : SECURITY TRAINING ) Government ( ) Retired Other Income:

Employment Status : ( X ) Employed Gross Annual Income: Php 360,000 Source of Other Income: ( ) Bonus Job Tenure ( for employed applicants ) : Previous Employer:

Self-employed

( ) Interests ( ) Property ( ) Share Current job ( 3 ) no. of yrs ( ) no. of mos. Previous job ( ) no. of yrs ( ) no. of mos. Previous Job Title:

BANKING RELATIONSHIP HSBC Customer: ( ) Yes ( X ) No If yes: ( ) Bank Account ( ) Credit card Time with HSBC ( ) yrs. ( ) mos. HSBC Acct Number: HSBC Card Number: Other Bank Name: Other credit card if any (non-declaration of cards held will delay application processing) (IMPORTANT) Other Banks you deal with Card Company Credit Card No. Credit Limit Member since 1) n/a 2) n/a Do you have a relative working at HSBC? ( ) Yes ( X ) No If yes, relationship: OTHER INFORMATION My preferred card delivery and billing statement delivery address is: ( ) Home ( X ) Office For Bank Use Only: Source Code: Agent Code: Agency Managers signature