COMPANY NAME
BUSINESS ADDRESS

ID picture taken within the last 6 months 3.5 cm. x 4.5 cm. (passport size) Computer generated or photocopy of picture is not acceptable

PERSONAL DATA and AUTHORIZATION FORM

NAME
POSITION

I, , after being sworn in accordance with law, do hereby:

Certify that the information contained in this document and its supporting schedule of my own knowledge is true and correct.

Authorize the following, pursuant to the provisions of Section 103-P of the Manual of Regulations for Non-Bank Financial Institutions (MORNBFI):

to conduct a background investigation on myself as in which include, among others, inquiring from the Watchlist Files of the Bangko Sentral ng Pilipinas; and

The Bangko Sentral ng Pilipinas to disclose its findings pertinent to the aforementioned inquiry on the said Watchlist Files and other sources to .

With the above authorization, I hereby waive my right to the confidentiality of the information that will be obtained as a result of the said inquiry, provided that disclosure of said information will be limited for the purpose of ascertaining my qualification or non-qualification for the said position.

Signature over Printed Name

SIGNED IN THE PRESENCE OF:

(Witness)	(Witness)

SUBSCRIBED AND SWORN to before me this ____ day of _________________ 20__ , affiant exhibiting to me his/her ______________________________ issued at ________________ on ________________ .

Notary Public

BIOGRAPHICAL DATA

PERSONAL INFORMATION:

SURNAME	GIVEN	MIDDLE	SUFFIX (e.g. Jr., III)
1. NAME :
2. TIN :	3. UPDATED AS OF :
4. OTHER NAMES USED, IF ANY :
5. MANAGEMENT LEVEL :	Director	Officer
6. DATE ELECTED / RE-ELECTED / APPOINTED / POSITION CHANGED :
7. RESIDENCE ADDRESS :
8. TELEPHONE NO. :	9. E-MAIL ADD :
10. BUSINESS ADDRESS :
11. TELEPHONE NO. :	12. E-MAIL ADD :
13. CIVIL STATUS :	Single	Married	Divorced/Separated	Widow
14. SEX :	Male	Female	15. CITIZENSHIP :
16. DATE OF BIRTH :	17. PLACE OF BIRTH :

FAMILY RELATIONS (Legitimate or Common-Law):

SURNAME	GIVEN	MIDDLE	SUFFIX (e.g. Jr., III)
18. NAME OF SPOUSE :

SURNAME	GIVEN	MIDDLE	SUFFIX (e.g. Jr., III)
19. NAME OF COMMON- LAW SPOUSE :

TRAINING/S:

20. Seminars/Training on Money Service Business, AML/CFT and other related fields

NATURE/TITLE	CONDUCTED BY	YEAR TAKEN

(continue in separate sheet if necessary)

WORK EXPERIENCE/S:

21. Present Position – Other Private Institution (Including Corporate Directorships)

NAME OF OFFICE	POSITION	DATE ASSUMED	INDICATE IF OWNER/ PARTNER/ STOCKHOLDER

(continue in separate sheet if necessary)

22. Present Position/s – Government (Including Directorships in Government Corporate Institutions)

NAME OF OFFICE	POSITION	DATE ASSUMED	INDICATE IF ELECTIVE OR APPOINTIVE AND PART/FULL-TIME

(continue in separate sheet if necessary)

23. Past Position/s – Other Private Institutions (Including Corporate Directorships)

DURATION (YEAR)
NAME OF OFFICE	POSITION	FROM	TO
(continue in separate sheet if necessary)

24. Past Position/s – Government (Including Directorships to Government Financial Institution)

DURATION (YEAR)
NAME OF OFFICE	POSITION	FROM	TO

(continue in separate sheet if necessary)