Personal Information

Complete Name:
(First/Middle/Last)

Company Name:

Home Address
      Street
      City/State Zip/Postal Code

Date of Birth:

Tel. No. : Fax No.:
SSS No.: Driver's License No.:

AUTHORITY TO CONDUCT CREDIT EVALUATION

TO: PCI Express Padala Inc.

RE: CREDIT INFORMATION

In connection with my application to be a licensed Express Padala agent, this will authorize to obtain credit report/information using the information shown below:

Complete Name:
(First/Middle/Last)

Address
      Street
      City/State Zip/Postal Code

Tel. No. : Fax No.:
SSS No.: Driver's License No.:

I certify that the above information is complete and accurate. I authorize the release of my credit statement and the release of information regarding my credit.

Important: Atlas Express Padala representative will call you to
confirm this application.