Mobility Service Application Form for

Solutions Corporate Managed Accounts

Company Information

1 COMPANY NAME
GOLD DELUXE PHILS. LTD. CO., INC.
4 AUTHORIZED CORPORATE/OFFICER SIGNATORY 1
POSITION IN COMPANY CONTACT NO.

2 REGISTERED BUSINESS ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

UNIT C 9TH FLR MARVIN PLAZA, 2153 CHINO ROCES AVENUE
E-MAIL ADDRESS

BARANGAY/MUNICIPALITY/TOWN AUTHORIZED CORPORATE/OFFICER SIGNATORY 2

PIO DEL PILAR, POSITION IN COMPANY CONTACT NO.

CITY/PROVINCE POSTAL CODE/ZIP CODE

E-MAIL ADDRESS
MAKATI CITY

NOTE: Business address must be the company's business address. It is within the
AFTER-SALES CORPORATE SIGNATORY 1
Philippine soil and not addressed to any P.O. box.
5 POSITION IN COMPANY CONTACT NO.

3 INDUSTRY
E-MAIL ADDRESS
MANUFACTURING FOOD POWER AND UTILITIES
MANUFACTURING NON-FOOD PETROLEUM
SEMICON IT AFTER-SALES CORPORATE SIGNATORY 2
DISTRIBUTION MEDIA POSITION IN COMPANY CONTACT NO.

LOGISTICS AND TRANSPORT FINANCIAL INSTITUTION

E-MAIL ADDRESS
EDUCATION REAL ESTATE AND CONSTRUCTION
RETAIL BPO
HEALTHCARE SERVICES HOSPITALITY 6 VAT TAX EXEMPTION
VAT OCT
GOVERNMENT
YES Attach BIR Certificate/Sample YES Attach BIR Certificate/Sample
OTHERS (Please specify) ____________________________________________ Account No. Account No.
✔ NO ✔ NO

Billing Instructions
7 DETAILED BILLING STATEMENT 8 BILL SUMMARY
How would you like to receive your detailed billing statement? Would you like to receive a bill summary?
YES NO
SOFT COPY (email to this address)

If yes, how would you like the bill summary?

SOFT COPY (email to this address)

HARD COPY (send to this preferred billing address)
ATTENTION:
First Name
HARD COPY (send to this preferred billing address)
Last Name ATTENTION:
First Name

DEPARTMENT
Last Name

ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

DEPARTMENT

BARANGAY/MUNICIPALITY/TOWN
ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

CITY/PROVINCE POSTAL CODE/ZIP CODE

BARANGAY/MUNICIPALITY/TOWN

CITY/PROVINCE POSTAL CODE/ZIP CODE

BY SUBMITTING THIS FORM, I CERTIFY THAT ALL THE ABOVE INFORMATION IS ACCURATE, AND I AGREE TO THE TERMS AND CONDITIONS OF THIS SERVICE.
Subscriber's Declaration For Globe Telecom's Use Only
I/We hereby confirm that the foregoing information is true and correct, I have checked and verified the supporting credit requirements against the
and that the supporting documents attached hereto are genuine and original documents and found them to be authentic and in accordance in
authentic and voluntarily submitted by the subscriber for the purpose of accordance with GLOBE TELECOM requirements.
an application for a Globe mobile service.
ACCOUNT MANAGER NAME/ID
I/We the authorized representative/s of the company hereby authorize
GLOBE TELECOM to obtain pertinent credit information from banks,
credit card companies, and other financial institution on the course DATE SIGNATURE
of credit investigation of the company's application, and I/We hereby
authorize the release of such information by the bank, credit card, and CORPORATE CODE
financial institutions from which credit information is requested.

I/We hereby confirm that I/We have read and understood the Terms and CORPORATEID NUMBER
Conditions stated on the reverse side of this form and that the company
shall comply with them and with any additional terms and conditions in YES (Please indicate number)
any certificate required to be executed in connection with any particular
NO
GLOBE TELECOM promotions or plans.

I/We acknowledge and agree to the minimum subscription period to the VPN SUBSCRIBER?
relevant Service availed of. If I choose to downgrade my plan, transfer YES (Please indicate number)
any rights or obligations of my subscription or terminate or cancel my
subscription within the minimum subscription period then I agree to pay NO
the relevant fees and penalties.
ASSIGNEE LIST NUMBER
I/We am aware of the fees, rates and charges relevant to the
Service availed of and I agree to pay the same within the due dates.
I understand that I will be subject to interest and penalties for REMARKS
late payment or non-payment stated in the Terms and Conditio
ns. MOBILE NUMBER ACCOUNT NUMBER
I/We agree that this Subscription Agreement shall govern our relationship
for the service currently availed of and service I will avail of in the future.
CUSTOMER CLASS ACCOUNT CATEGORY
I/We consent to the company’s disclosure of information concerning
myself/ourselves or my/our subscription to financial institutions, credit
CREDIT CHECKED/DATE
bureaus or similar organizations.

I/We hereby confirm that any device issued by GLOBE TELECOM is my full APPROVED/DATE
responsibility. The damage to or loss of device is not a valid ground not
to pay the MSF and other charges. GLOBE TELECOM has no obligation to
ACTIVATED/DATE
repair or replace a damaged device outside the manufacturer’s warranty.

For Corporate Managed

AUTHORIZED SIGNATORY (Signature over printed name)

__________________________________________________________________________________________________________________________

DATE

__________________________________________________________________________________________________________________________

AUTHORIZED SIGNATORY (Signature over printed name)

__________________________________________________________________________________________________________________________

DATE

__________________________________________________________________________________________________________________________
 Mobility Service Application Form
Solutions for Corporate Individual
Personal Information Employment/Financial Information
1 Are you an existing Globe Telecom subscriber?
18 EMPLOYER/BUSINESS NAME
ACCESS/AREA CODE MOBILE/PHONE NO.
GLOBE MOBILE PHONE
19 INDUSTRY
MANUFACTURING FOOD BPO
GLOBE TATTOO
MANUFACTURING NON-FOOD FINANCIAL INSTITUTION
GLOBE LANDLINE SEMICON REAL ESTATE AND CONSTRUCTION
DISTRIBUTION POWER AND UTILITIES
2 MR. MRS. 3 GENDER LOGISTICS AND TRANSPORT PETROLEUM
OTHERS _____________________ MALE FEMALE EDUCATION IT
RETAIL MEDIA
4 BIRTHDAY (mm/dd/yyyy)
5 CIVIL STATUS
SINGLE WIDOW/WIDOWER HEALTHCARE SERVICES HOSPITALITY
GOVERNMENT OTHERS (Please specify) _____________
MARRIED LEGALLY SEPARATED

6 LAST NAME 20 COMPLETE BUSINESS ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

BARANGAY/MUNICIPALITY/TOWN

7 FIRST NAME
CITY/PROVINCE POSTAL CODE/ZIP CODE

8 MIDDLE NAME

21 OFFICE PHONE NUMBER

AREA CODE PHONE NO.
9 MOTHER'S FULL MAIDEN NAME (First, Middle, Last)

22 YEARS IN COMPANY CURRENT POSITION HELD

10 HOME OWNERSHIP

OWNED (_____ yrs of stay) RENTED (P______________ /month) 23 PERSONAL MONTHLY INCOME
BELOW P10,000 P15,000 - P24,999 P35,000 - P50,000
LIVING WITH RELATIVES MORTGAGE (P______________ /month) P10,000 - P14,999 P25,000 - P34,999 ABOVE P50,000

COMPANY-OWNED 24 AUTHORIZED CONTACT PERSON IN YOUR ABSENCE (First, Middle, Last)

11 COMPLETE HOME ADDRESS (Unit/Floor/Building Name/Street No./Street Name)

25 RELATION OFFICE PHONE NUMBER
AREA CODE PHONE NO.
BARANGAY/MUNICIPALITY/TOWN
Billing Instructions
CITY/PROVINCE POSTAL CODE/ZIP CODE
26 BILLS TO BE SENT TO MY: HOME ADDRESS BUSINESS ADDRESS
ENROLL IN PAPERLESS BILLING: YES (if yes, please specify email:) NO
*Statement of Account/bill will automatically be delivered to other address in case of
moved out/return to sender.
NOTE: Hard copy will no longer be sent to Home/Business area.

12 HOME TELEPHONE NUMBER

AREA CODE PHONE NO.
MOBILE NUMBER
ACCESS CODE MOBILE NO. Auto-Charge
27 Would you like to automatically charge your monthly bill/s to your credit card account?
YES NO
13 EMAIL ADDRESS (Primary) ISSUING BANK
CREDIT CARD NUMBER CARD EXPIRATION DATE (mm/dd/yyyy)
EMAIL ADDRESS (Alternate)
OTHER GLOBE ACCOUNTS TO BE ENROLLED

14 TAX IDENTIFICATION NUMBER (TIN) GSIS/SSS

Service Information
28 SERVICE TYPE
15 AFFILIATED MAJOR CLUBS/ORGS CITIZENSHIP
WIRELESS VOICE WIRELESS DATA VAS OTHERS _____________________

29 PLAN NAME MONTHLY SERVICE FEE (MSF)

16 COUNTRY (If foreigner) PASSPORT NUMBER

ACR NO./ i-CARD NO. PASSPORT EXPIRY DATE (mm/dd/yyyy)

30 ADD-ONS
1 2 3 4

5 6 7 8

31 PRIMERS
17 SPOUSE NAME (If applicable)
LAST NAME
1 2 3 4

32 SPECIAL FEATURES (Tick to deactivate)

INTERNATIONAL ROAMING IDD MOBILE DATA OTHERS _____________________
MIDDLE NAME
33 BUNDLE INFORMATION
GADGET GC OTHERS _____________________
FIRST NAME
34 GADGET INFORMATION (Gadget brand) GADGET MODEL

SPOUSE'S DATE OF BIRTH (mm/dd/yyyy) PROFESSION OF SPOUSE / COMPANY NAME

GADGET BASE PRICE GADGET CASHOUT (if Business Plus, amortization amt)

MSA NO. POSITION

35 MINIMUM SUBSCRIPTION PERIOD
6 MONTHS 12 MONTHS 24 MONTHS OTHERS _____________________

BY SUBMITTING THIS FORM, I CERTIFY THAT ALL THE ABOVE INFORMATION IS ACCURATE, AND I AGREE TO THE TERMS AND CONDITIONS OF THIS SERVICE.
Employee Certification List For Globe Telecom's Use Only
This document is to certify that the employees whose names are I have checked and verified the supporting credit requirements against the
included in the attached list, are regular employees (“Employees”) of original documents and found them to be authentic and in accordance in
______________ (“Company”) receiving communication allowance or accordance with GLOBE TELECOM requirements.
subsidy to cover their telecommunication expenses for official business,
hence, all benefits and privileges accorded by Globe Telecom, Inc. ACCOUNT MANAGER NAME/ID
(“Globe”) to Company for mobile telecommunication subscriptions may
be extended to them. Said benefits and privileges however, will be made
available to the Employees on condition that they remain employees DATE SIGNATURE
of the Company. In the event of resignation, retirement or termination
of employment of any Employee, Company shall immediately inform CORPORATE CODE
Globe in writing of such fact and Globe may withdraw the benefits and
privileges extended to such Employee.
CORPORATEID NUMBER
It is understood that each of the Employees shall be solely responsible
for the obligations arising from their respective subscriptions to Globe YES (Please indicate number)
mobile telecommunication services.
NO

___________________________________________ ______________
VPN SUBSCRIBER?
Name & Signature of HR Authorized Signatory Date
YES (Please indicate number)
___________________________________________
Company Name NO
Please attached photocopy of ID of HR Authorized Signatory
ASSIGNEE LIST NUMBER

Subscriber's Declaration
REMARKS
I/We hereby confirm that the foregoing information is true and correct,
and that the supporting documents attached hereto are genuine and
MOBILE NUMBER ACCOUNT NUMBER
authentic and voluntarily submitted by the subscriber for the purpose of
an application for a Globe mobile service.
CUSTOMER CLASS ACCOUNT CATEGORY
I/We the authorized representative/s of the company hereby authorize
GLOBE TELECOM to obtain pertinent credit information from banks,
credit card companies, and other financial institution on the course CREDIT CHECKED/DATE
of credit investigation of the company's application, and I/We hereby
authorize the release of such information by the bank, credit card, and APPROVED/DATE
financial institutions from which credit information is requested.

I/We hereby confirm that I/We have read and understood the Terms and ACTIVATED/DATE
Conditions stated on the reverse side of this form and that the company
shall comply with them and with any additional terms and conditions in
any certificate required to be executed in connection with any particular
GLOBE TELECOM promotions or plans.

I/We acknowledge and agree to the minimum subscription period to the

relevant Service availed of. If I choose to downgrade my plan, transfer
any rights or obligations of my subscription or terminate or cancel my
subscription within the minimum subscription period then I agree to pay
the relevant fees and penalties.

I/We am aware of the fees, rates and charges relevant to the

Service availed of and I agree to pay the same within the due dates.
I understand that I will be subject to interest and penalties for
late payment or non-payment stated in the Terms and Conditio
ns.
I/We agree that this Subscription Agreement shall govern our relationship
for the service currently availed of and service I will avail of in the future.

I/We consent to the company’s disclosure of information concerning

myself/ourselves or my/our subscription to financial institutions, credit
bureaus or similar organizations.

I/We hereby confirm that any device issued by GLOBE TELECOM is my full
responsibility. The damage to or loss of device is not a valid ground not
to pay the MSF and other charges. GLOBE TELECOM has no obligation to
repair or replace a damaged device outside the manufacturer’s warranty.

Corporate Individual
Name and Signature of Subscriber Date

__________________________________________________________________________ ____________________________