HOMEPAGE
ONLINE CREDIT APPLICATION
UNIT INFORMATION
SKU
Model
Category
Brand
Downpayment
Color
White
Black
Red
Blue
Magenta
Gray
Green
Yellow
Orange
Pink
Terms
3 months
6 months
12 months (1 yr)
24 months (2 yrs)
36 months (3 yrs)
Area
Branch
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
Single
Married
Partner
Widowed
Divorced
Separated
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
---SELECT---
Single
Married
Partner
Widowed
Divorced
Separated
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.
Check (
)
I Certify That the data you given is true?
Submit
