ONLINE CREDIT APPLICATION

UNIT INFORMATION

Model

Category

Brand

Color

Terms

Area

Branch

UNIT INFORMATION

Requirements - Motorcycle Only

Driver's License No.

Note: For Motorcycle Installment a Driver Licensed is required!

APPLICANT

First Name

Last Name

Contact No.

E-mail

Civil Status

Age

Address 1

Address 2

Landmark

Father's Name

Contact No.

Mother's Name

Contact No.

SPOUSE

First Name

Last Name

Contact No.

E-mail

Civil Status

Age

Address 1

Address 2

Father's Name

Contact No.

Mother's Name

Contact No.

SOURCE OF INCOME

Source of Income

Employed

Self Employed

if OFW / Seaman

Other Source of Income Employed

Company

Contact No.

Company Address

Income Information / Capacity to Pay

LandMark

NUMBER OF DEPENDENTS

Name

Educational Level

Name

Educational Level

I Certify that the data I have disclosed in this credit application are true to my knowledge and hereby authorized DUEKSAM,INC. and it's authorized representatives to conduct the corresponding credit investigation thereon.

WARNING: SALES AGENTS are NOT AUTHORIZED to collect or receive payments. Any made or entrusted to any Person not remitted to the office is null and void. ALWAYS ASK FOR A RECEIPT.

I Certify That the data you given is true?