Position

Type of Vessel
—Please choose an option—TankerNon-tankerOffshoreCruise

Mobile Number

Email Address

First Name

Middle Name

Last Name

Birth Date

Permanent Address

Manning Agency

Name of Vessel

Crewing Manager

Departure Date

Monthly Expenses

Person in-charge to pay

Contact Number (person in-charge)

I hereby certify that the above information are true and correct and that JuanClik Lending Corporation reserves the right to reject my application for any incorrect data that I provided. I hereby authorize JuanClik Lending Corporation to check my Bank/Creditors on the status of my deposits/liabilities. I understood that financial insitutions’ share/collect credit information either among themselves or through Credit Information Corporatio as mandated by Republic Act 9510 or other credit bureaus. I interpose no objection to such sharing of credit information and I authorize JuanClik Lending Corporation to disclose the same pertaining to me and my loan account as the JuanClik Lending Corporation sees fit. I hold JuanClik Lending Corporation free and harmless in its participation to this industry practice, which I see as a necessary procedure in creating a healthy balance between reliable credit information and this safeguarding consumer protection that ultimately redounds to my benefit.