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					           CUSTOMER INFORMATION SHEET
    NOTE: Please answer with N/A for questions not applicable to your application Incomplete
                        entries will delay the processing of application
      NEW APPLICATION                                                          CHANGE of                      DATE
           POSTPAID WIRED LANDLINE                                 OWNERSHIP /
           POSTPAID WIRELESS LANDLINE (PLP)                        SUPERSEDURE                                CUSTOMER NO.
                                                                   ( Let t er of r equest must be submit t ed
           PREPAID WIRED LANDLINE (SULIT TALK)                     by t he cur r ent subscr iber on r ecor d)

                                                                      CUSTOMER PERSONAL DATA
        MR.        MS.       MRS. CUSTOMER NAME
       TITLE___________________
                                                                     LASTNAME                                             FIRSTNAME

  IDENTIFICATION CARD (any of the following TIN, Driver's License, PRC ID, SSS/GSIS, Voter's ID, Current Company ID, P
PHYSICAL ADDRESS (where the telephone will be installed)


 BLK & LOT/HSE #       RM/UNIT/DOOR/STALL          FLOOR                   BUILDING/APARTMENT NAME                             SUBD/VILLAGE
BILLING ADDRESS (where the monthly bills will be sent. If different from above address)



 BLK & LOT/HSE #       RM/UNIT/DOOR/STALL          FLOOR                   BUILDING/APARTMENT NAME                             SUBD/VILLAGE

HOME OWNERSHIP                                                                                                                           TELEPHONE WIRING
        OWNED                                      LIVING WITH                                      RENTED__________________             CONDUIT READY
                                                   RELATIVES/PARENTS
          Owner, Rented Out                                                                                    Landlord
          Owned, Not Mortgaged                                                                                 Tenant
          Owned, Mortgaged
                             YEARS OF STAY_________________
EMAIL ADDRESS                                                                                       TELEPHONE NO.                        FAX NO.



Do you own a PC?                                     Where do you access the internet?                                                     Do you use long distance services?
      Yes                          No                       HOME - if at home, who is/are your ISP/s?                                             Yes
  if YES, with modem?                                       ____________________________                                                    if YES, please check
      Yes                          No                       Internet Café                                                                           Domestic / NDD               OVERSE
                                                                                                     WORK AND FINANCIAL INFORMATION
 EMPLOYMENT STATUS                                 EMPLOYER's/BUSINESS NAME                                                              TYPE OF BUSINESS

    Student
    SELF-EMPLOYED                                  EMPLOYER's/BUSINESS ADDRESS

    UNEMPLOYED WITH INCOME
                                                  DO YOU OWN A CREDIT CARD?
    UNEMPLOYED WITHOUT INCOME                     CARD NAME / TYPE __________________________________________________________________________________________________
    EMPLOYED (SAME FIRM)                   FOR    CARD No.__________________________________________________________________________________________________________ Would you like to auto
                                                  charge your monthly PLDT bill to your credit card account?
MORE THAN 2 YRS
    EMPLOYED (SAME FIRM)                   FOR
                                                                         YES                        NO
LESS THAN 2 YRS
                                                                                                                  SPOUSE PERSONAL DATA
 NAME (Last,First,Middle Name)                                                                                                            BIRTHDAY (Month/Day/Year)
 NAME (Last,First,Middle Name)                                                                                                                     BIRTHDAY (Month/Day/Year)


EMPLOYER's/ BUSINESS NAME & ADDRESS                                                                                                                POSITION




                                                                                                                                         SERVICE REQUEST

    FEATURES                                                                                                                                           CALLER ID BUNDLE (Call
       NDD___________________            IDD____________________                                                                                       CALL WAITING BUNDLE
       MEGA BUNDLE (Call Waiting, Call Forwarding, Speed Calling)                                                                                      CALL BARRING(    PLD
       SUPER BUNDLE (Mega Bundle + 3-Party Conference)                                                                                                 OTHERS. ____________




           PLAN 850                                                              PLAN 1,100                                                         PLAN TYPE:
                                                                                                                                                   BUNDLE PLAN 990 (Unlimited DSL + L
           OTHER__________________                                               OTHER__________________                                           BUNDLE PLAN 1299 (Unlimited DSL +
                                                                                                                                                   XPERIENCE PLAN 999 (High Speed DSL

                                                                                                                                                   XCITE PLAN 1995 (High Speed DSL + W
                                                                                                                                                   XCEL PLAN 3000 (High Speed DSL + W
                                                                                                                                                    INSTALLATION:
                                                 Unlimited voice and internet                                                                      myDSL QUICK INSTALL KIT (QIK)
                                                                                                                                                   REGULAR INSTALLATION
                                                                                                                                                    MODEM TYPE:
                                                                                                                                                   STANDARD MODEM
                  PLAN 990                                                 OTHER: __________                                                       WI-FI MODEM
                                                                                                                                                    OTHERS:
               TELEPHONE ATTACHMENT OTHER THAN PLDT-PROVIDED UNIT                                                                                  UNLIMITED PLDT to PLDT NDD (with N
          IMPORTANT: If you intend to attach a device to the telephone service, check the appropriate item's               below.
Notwithstanding any indications to the contrary,     the attachment of any device to PLDT's              telephone service shall be
                                                                                                                                                   ID-DSL CALLER'S PACKAGE (with IDD a
subject to prior approval and payment of applicable charges. if any PLDT            will institute appropriate action for any disallowed /
undeclared attachment to the telephone service.


                          Modem                          Fax Machine                      Tel Set ___________

              Card Reader                    Answering Machine                 Others______________




           DIRECTORY LISTING
                 PLDT telephone number only

                 Please include other info when requested via directory or 187

                                                                                                                                                   PLAN 799
               • Cellphone No. _______________________         • Fax No.: ________________________                                • E-
mail address / Website ______________        • Others: _________________________                                                                   PAY-PER-SURF




                                   My signature below signifies that all information stated herein are true & correct to the best of my knowledge.                            Further,
                           read & understand and will abide by the terms and conditions found at the back of this form.

                                                                                                                               CONFORME
____________________________________
Subscriber / Authorized Representative       Signature Over Printed Name
                                      Date
                                                                                       FOR RESIDENTIAL USE
                                                                                  S.O NO.____________________
           DATE                                                             ACCOUNT No.

           CUSTOMER NO.                                                     TELEPHONE No.
mit t ed
ecor d)

ONAL DATA
                                                                                MOTHER's FULL MAIDEN NAME


                                     MIDDLENAME

er's ID, Current Company ID, Pag-ibig, Senior Citizen ID)________________



                                    BARANGAY                             CITY/TOWN                        PROVINCE




                                    BARANGAY                             CITY/TOWN                        PROVINCE
 TELEPHONE WIRING                             CONTACT PERSON and CONTACT NUMBER
 CONDUIT READY




 FAX NO.                                                        CELLULAR No.



   Do you use long distance services?                           What do you use to call long    Type of long distance calls?
                                                                distance?                  T
                                            No                  Telephone
    if YES, please check                                              Cellular Phone                   Personal
             Domestic / NDD               OVERSEAS/IDD               Internet                          Business
L INFORMATION
 TYPE OF BUSINESS                                               POSITION


                                                                OFFICE TEL. No.


 _____________________________                                  MONTHLY INCOME
 ____________________________ Would you like to automatically          Over P50,000                           P10,001 - 15,000
                                                                            P30,000 - P50,000         Below P10,000
                                                                           P15,001 - P30,000


NAL DATA
  BIRTHDAY (Month/Day/Year)                                     MONTHLY INCOME
 BIRTHDAY (Month/Day/Year)                      MONTHLY INCOME


 POSITION                                       OFFICE TEL. No. / CELLALULAR No.




QUEST

     CALLER ID BUNDLE (Caller ID, Call Forwarding, Speed Calling
     CALL WAITING BUNDLE (Call Waiting, Call Forwarding, Speed Calling)
     CALL BARRING(    PLDY 108 / 109.       Total Call Barring )
     OTHERS. _____________________________________


               (Minimum Requirements Computer must have a LAN card Installed,
               Pentium II and CD- ROM drive?

  PLAN TYPE:
BUNDLE PLAN 990 (Unlimited DSL + Landline + Watchpad)
BUNDLE PLAN 1299 (Unlimited DSL + Landline + Watchpad)
XPERIENCE PLAN 999 (High Speed DSL + Watchpad)

XCITE PLAN 1995 (High Speed DSL + Watchpad)
XCEL PLAN 3000 (High Speed DSL + Watchpad)
  INSTALLATION:
myDSL QUICK INSTALL KIT (QIK)
REGULAR INSTALLATION
  MODEM TYPE:
STANDARD MODEM




UNLIMITED PLDT to PLDT NDD (with NDD activation)
ID-DSL CALLER'S PACKAGE (with IDD activation)




                                Watch the hottest channels for FREE
                              Register at www.pldtwatchpad.com once myDSL service is installed




               Now, everywhere is home! Experience the convenience of wireless
               broadband internet nationwide




est of my knowledge.       Further, this signifies that I have

				
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posted:4/6/2012
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