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COYUITO HOUSE 119 CARLOS PALANCA, JR. ST. LEGASPI VILLAGE MAKATI CITY

P.O. BOX 3831 CPO 1099 MANILA* TEL NOS. 8104916 TO 35* FACSIMILE 8102991

CLIENT INFORMATION SHEET – FOR INDIVIDUAL

Complete Name : Macalinao Construction Works

Present Address : # 14 Grayline Ventures Bldg. Arayat St., Mandaluyong City

Permanent Address :

Contact Numbers: Telefax-654-6705 Nationality :

Date of Birth : Place of Birth :

TIN : SSS/GSIS No :

Nature of Work :

Nature of Self Employment / Business :

Source of Funds L

Nature of Beneficiary, If applicable :

Clients Signature : Date Signed :

This portion of to be filled up by Prudential Guarantee & Assurance, Inc,

Client : Intermediary :

Policy No :

As mandatory of Philippine Anti-Money Laundering Act and Re Implementing Rules and Regulations.

COYUITO HOUSE 119 CARLOS PALANCA, JR. ST. LEGASPI VILLAGE MAKATI CITY

P.O. BOX 3831 CPO 1099 MANILA* TEL NOS. 8104916 TO 35* FACSIMILE 8102991

APPLICATION FOR BOND

(For Individual)

The undersigned hereby applies for a _______________________________________________ bond in the amount of P____________________________ in favor of ___________________________________ to fully and faithfully guarantee __________________________________________________________

______________________________________________________________________________________

(Indicate details of undertaking, or attach copy of the contract and/or corresponding documents for which bond is required)

For your consideration, I am giving hereunder the following information:

1. Name_______________________________________________________________________________

2. Age ________ Nationality____________________________ Civil Status _______________________

3. Residence _________________________________________ Tel. No. __________________________

4. Office Address...