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 COMPANY NAME
BUSINESS ADDRESS

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 Subsection 4511N.2 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 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)