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OpenForm

Truth in Lending Act

Important:
• Application forms received without requirements will not be processed.
• Your home or business address must be within a 30km. radius of a BPI or BPI Family Bank branch or Provincial Business Center.

CHOOSE THE BPI EXPRESS CREDIT CARD THAT'S RIGHT FOR YOU!

Learn more about the features of the BPI Express Credit Cards. Click Here

BPI Blue MasterCard: The Sensible Card BPI Signature: Your Travel and Lifestyle Card
Earn rewards points and freebies every time you use your BPI Blue Experience the best the world has to offer with the card that
MasterCard! Enjoy your cash advance facility worldwide plus 24/7 complements your Signature lifestyle. Enjoy delightful travel
BPI Visa Signature

BPI Blue MasterCard

access to our International Toll-free Service. rewards, global services and exclusive privileges only for you.

BPI Gold MasterCard: The Premium Card

The most exclusive perks. The most premium privileges. Because you
BPI Gold MasterCard

deserve only the best, you deserve to have a BPI Gold MasterCard. BPI SkyMiles MasterCard: The Pure Mileage Card
Discover the world and travel to your dream destinations with your
Petron-BPI MasterCard: The Full Service Motorist Card BPI SkyMiles MasterCard. Earn miles as you spend, anytime and
BPI SkyMiles MasterCard

Every motorist's dream, the Petron-BPI MasterCard offers 3% fuel anywhere you use your card!
Petron-BPI MasterCard
rebate at participating Petron stations, 24-hour price shield for fuel,
and so much more!

BPI Edge MasterCard: The Value for Style Card

The BPI Edge MasterCard gives more value to being in style so you
BPI Edge MasterCard

can have more , do more and enjoy more! Get fabulous discounts at BPI Amore Visa: The Lifestyle Shopper Card
the hippest shops, coolest clubs and most exclusive events. BPI and Ayala Malls give you the card that offers an ultimate mall and
BPI Amore Visa
lifestyle experience, Enjoy shopping and dining rebates, free lounge
access, discounts on cinema tickets and so much more from the card
that loves you most!

BPI eCredit: The Internet Shopping Card

Enjoy your cyber shopping spree with eCredit! It's safe and convenient -
just shop online and settle your balance the secure and easy way! Get
this free with any BPI Express Credit MasterCard

BPI eCredit: The Internet Shopping Card will be automatically issued as a free companion card upon approval of BPI Express Credit and shall be subject to the BPI Credit Card Terms and Conditions.

Fill out the Application Form to enjoy Real Thrills!

Please fill-out COMPLETELY.

I. ABOUT ME
If you are an existing SkyMiles member, please provide your name as it appears on your SkyMiles card or e-statement

Last Name Rosal

First Name Serjoe
Middle Name Name
Name to appear on card
(must not exceed 23 characters, including spaces) Serjoe Name Rosal

SkyMiles Membership Number

(For existing SkyMiles members. Otherwise, please leave this blank)

All SkyMiles program apply. To review the rules, please

visit delta.com/memberguide

Mother's Full Maiden Name Julieta Tubiera Name

Birthdate (mm/dd/yyyy) October 22 , 1983
Place of Birth Manila, Philippines
Sex Male
Civil Status Married
No. of Dependents 1
T.I.N. (Tax Identification Number)

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231 - 012 - 406 - 000
SSS or GSIS Number 3389974825
Car Ownership MORTGAGED
No. of cars owned 2
If mortgaged Php 33770 per month
Citizenship Filipino
Non-Filipino (please specify) N/A

Preferred Billing Address

Office
(where correspondences will be sent)

Residence Address
(street/road/avenue, subdivision
B4 Bldg2 Bahay Caridad Bayani
/village/compound)

Residence Address (district/barangay)

Bgy. Dona Imelda
Residence Address (city)
Quezon City
Residence Address (zip code)
1113
(Please fill out if not the same as Home Address.)

Permanent Address (street/road/avenue, subdivision L9 B206 Heritage Spring Homes

/village/compound)

Permanent Address (district/barangay)

Barangay Puting Kahoy
Permanent Address (city)
Silang, Cavite
Permanent Address (zip code)
4118

Home Ownership OWNED - CLEAN

If mortgaged or rented PhP 0.00 per month
Years of Stay 6
Home Phone Number 46 - 8403273
Fax Number 02 - 85238726
Mobile Number 09212408886
Send me SMS/MMS promo updates Yes
Email Address [email protected]
Kindly indicate if you're related to a BPI Director, Officer, Stockholder and Related Interest (DOSRI):
Name: N/A
Relationship: - Relationship -

II. ABOUT MY WORK

Employment Type SELF-EMPLOYED
Others CHLOJJ Trading - S&M Director
Years w/ Present Employer/Business 4
Employer/Business Name CAPITAL Medical Supplies
Position SELF EMPLOYED
(For Insurance agents, provide Insurance Commision
License Number)
N/A
Nature of Business/Industry WHOLESALE TRADE

Office/Business Address
(street/road/avenue, subdivision/village/compound) L9 B206 Heritage Spring Homes

Office/Business Address (district/barangay)

Puting Kahoy
Office/Business Address (city)
Silang, Cavite
Office/Business Address (zip code)
4118

Office/Business Phone Number 46 - 8403273

Local/Ext Number -

Best time to Call Tuesday 9:30 AM - 10:30 AM

Note: Within office hours
Mondays thru Fridays
Fax Number 02 - 85238726
Email Address [email protected]
Gross Annual Income Php 1000000
Previous Employer MZP Arch'l & Eng'g Consultancy
Years w/ Previous Employer/Business 11

III. ABOUT MY SPOUSE

Last Name Rosal
First Name Florence
Middle Name Vargas
Birthdate June 07 , 1976
Employer/Business Name Hamad Medical Corporation
Position SUPERVISORY
Years w/ Present Employer/Business 6

Office/Business Address Child Devt Ctr, Rumailah Hosp.

(street/road/avenue, subdivision/village/compound)

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Office/Business Address (district/barangay)

Rumailah
Office/Business Address (city)
Doha, Qatar
Office/Business Address (zip code)
- Zip Code -

Office/Business Phone Number 97 - 4 4439 5777

T.I.N. (Tax Identification Number) 202 - 179 - 758 - 000
Gross Annual Income Php 2500000

IV. ABOUT MY FINANCES/BANK RELATIONSHIP

Important: Please provide complete information so your application can be immediately processed. If a field does not apply, please type "N/A" in the
space. Your home or business address must be within a 30km. radius of a BPI or BPI Family Bank branch or Provincial Business Center. Click here for
the requirements.
Note: Income document requirement is waived for existing Principal cardholders of the banks with:
at least P30,000 credit limit
at least 12 months tenure

Please provide complete details.

MY OTHER CREDIT CARDS (if any)

Expiry Date
Credit Card Company Card Number Credit Limit
(mm/yyyy)
1. Metrobank Card Corporation 5464981602058488 359000 09/2024
2. - Credit Card Company -
3. - Credit Card Company -

MY BPI/BPI FAMILY BANK ACCOUNTS (if any)

Account Number Deposit Type Branch Location
1. 9585005611 Checking BPI
2. 8984012927 Dollar BPI
3. 2925009108 Checking BPI

MY OTHER BANK ACCOUNTS

Bank
1. BDO
2. Metrobank
3. Landbank

MY OTHER CREDITORS (if any)

1. Creditor N/A
Date Granted (mm/dd/yyyy) N/A N/A , N/A
Term N/A
Amount Granted Php 0.00
Monthly Amortization Php 0.00 per month

2. Creditor N/A
Date Granted (mm/dd/yyyy) N/A N/A , N/A
Term N/A
Amount Granted Php 0.00
Monthly Amortization Php 0.00 per month

V. MY SUPPLEMENTARY CARDHOLDERS- FREE FOR LIFE: FIRST SUPPLEMENTARY CARD

Must be at least 13 years old
Must submit a copy of a valid ID with picture

1. Last Name
First Name
Middle Name
Name to appear on card
(must not exceed 23
characters, including spaces)
Relationship
Birthdate (mm/dd/yyyy) - Month - - Day - , - Year -
Sex - Sex -

2. Last Name
First Name
Middle Name
Name to appear on card
(must not exceed 23
characters, including spaces)
Relationship
Birthdate (mm/dd/yyyy) - Month - - Day - , - Year -
Sex - Sex -

VI. MY PERSONAL REFERENCES

Name Residence/ Employer/ Employer/

(Last/First/Middle) Employment Address Business Name Business Phone Nos.
1.

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Medlej/Adel Doha, Qatar MZP Arch'l & Eng'g Consulta +97455117013
2. Hattar/Emad Riyadh. Saudi Arabia Bin Jarallah Est Tdg & Gen +966503412809

DECLARATION
I certify that the information given by me is true and correct and that any material misrepresentation or falsity therein shall be
construed as an act to defraud BPI for which civil and/or criminal liability can be pursued against me. I hereby authorize BPI to: (i)
inquire about and investigate all the declared information from whatever sources BPI may consider appropriate; (ii) use any
contact details to communicate to me for whatever purpose; (iii) disclose any information herein provided to any person or entity.
For this purpose, I agree to indemnify and hold BPI free and harmless from any and all claims, liabilities, damages, suits or causes
of action of whatever nature, now or hereafter arising from or in connection with the foregoing authorization. Further, I agree that:
(i) the application form and the related documents submitted to BPI shall not be returned to me for whatever reason; (ii) in case of
disapproval of my application, BPI is under no obligation to provide me with the reason for such decision; and (iii) BPI reserves the
right to restrict the use of or to terminate/cancel the card without need of prior notice from BPI, if it is later determined that the
information certified by me is false. In the event that my application is approved, my use of the credit card shall be deemed my
acceptance/agreement with the terms and conditions governing the issuance and the use of the BPI Express Credit Card as printed at
the back of the card carrier which I will receive together with my credit card. I acknowledge that the said terms and conditions may
likewise be viewed in the BPI Cards website. I accept liability for all charges to the principal card and supplementary cards. Any
alterations, amendments, exceptions, reservations or scribblings made by me herein, in the BPI Express Credit Card terms and
conditions, as well as in the provisions contained in the Statement of Account (SOA), Installment Plan contract, Charge Slip, other
card documents, Suretyship Agreement and/or such other related instruments or documents, not approved in accordance with
BPI's appropriate procedures, shall not be valid and binding.

I have read and understood completely the Terms and Conditions governing the issuance
and use of BPI Express Credit Cards. I also reconfirm my agreement to the Declaration
stated above.

Please wait for the application confirmation page to appear to confirm that
your application has been received.

Submit Reset

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