CUSTOMER DATA SHEETL
Please complete all sections of this form and select appropriate options.

Customer (Required) New CustomerExisting, Info Changes Only

Section I - Company Profile Information

BIR Registered Business Name (Required)

Trade Name (Store Name) (Required)

Business Landline Number/s (Required)

Fax Number/s (Required)

Business Mobile Number (Required)

Business E-mail Address (Required)

Business Type (Required) Sole PartnershipPartnershipCorporation

Industry Segment (Required) Quick Service RestoLocal BakeryRestaurantCommissariesCafeHotelBed & BreakfastResortDealer / ResellerConcessionaires

Tax Identification Number (TIN) (Required)

VAT (Required) With VATNon-VATVAT-ExemptedZero-Rated

VAT Registration No. (Required)

Section II - Delivery Address

Unit No./House Number (Required)

Street (Required)

Barangay (Required)

City (Required)

Province (Required)

District / Region (Required)

Postal Code (Required)

Section III - Billing Address

Unit No./House Number (Required)

Street (Required)

Barangay (Required)

City (Required)

Province (Required)

District / Region (Required)

Postal Code (Required)

Section IV - Point Person Information

Section V - Authorized Representative

Warehouse
Name (Required)
Contact Number (Required)
Designation (Required)
Signature (Required)

Accounting
Name (Required)
Contact Number (Required)
Designation (Required)
Signature (Required)

Purchasing
Name (Required)
Contact Number (Required)
Designation (Required)
Signature (Required)

Others
Name (Required)
Contact Number (Required)
Designation (Required)
Signature (Required)

Section VI - Billing & Collection Issues

Required Billing Attachments (Required) Countered InvoicePurchase OrderDelivery NoteOthers

Others, Please specify: (Required)

Other Billing Requirements: (Required)

Method of Payment: (Required) Check Pick UpBank TransferCOD

Check pick up at: (Required)

Preferred Collection Days (Required) MondayTuesdayWednesdayThursdayFriday

Required Collection Documents (Required) Collection ReceiptCompany IDCertification, please specifyOthers, please specify

Please specify: (Required)

Other Collection Instructions (Required)

Section VII - Declaration

I hereby declare that the information given above and in any documents attached or requested by HICAPS Marketing Corporation in relation to this declaration is to the best of my knowledge is true, correct and complete in every respect. I hereby understand that non-disclosure/falsification of information as herein required shall be grounds for the termination of credit terms once approved and/or legal action against me / us.

Name (Required)

Designation (Required)

Date (Required)

Signature (Required)

Section VIII - Attachements

Photocopy of 2 valid government issued id of the Owner/Officer-In-Charge/Authorized Signatory (Required)

Photocopy of Business Permits (DTI, SEC Registration, Mayor’s Permit) (Required)

Certificate Of Registration (Form 2303) (Required)

Proof of billing (electric bill, water bill, etc.) (Required)

PLEASE WAIT FOR THE CONFIRMATION MESSAGE BEFORE CLOSING. SUBMISSION MAY TAKE LONGER DEPENDING ON THE ATTACHEMENT/S FILE SIZE.