EVERGREEN STOCK BROKERAGE AND SECURITIES, INC.

6/F TOWER ONE & EXCHANGE PLAZA, AYALA TRIANGLE, AYALA AVE., MAKATI CITY
CUSTOMER ACCOUNT INFORMATION FORM
___________ INDIVIDUAL __________ JOINT ACCOUNT
ACCOUNT TYPE: ( ) CASH ( ) DISCRETIONARY ( ) MARGIN ( ) INSTITUTIONAL

NAME: ___________________________________________________ BIRTH DATE: ____________________________________________________

NATIONALITY: _________________________________________________ BIRTH PLACE: ____________________________________________________

TIN NO. : ______________________________________________________ SSS / GSIS NO. : ____________________________________________________

NAME OF SPOUSE: ___________________________________________

RESIDENCE ADDRESS: ________________________________________________________ RES. TELEPHONE NO.. ________________________________________

_________________________________________________________________________________ FAX NO.. ________________________________________

OCCUPATION: ____________________________________________ EMPLOYER: ____________________________________________________

BUSINESS ADDRESS: __________________________________________________________ OFC. TELEPHONE NO. ____________________________________.

_________________________________________________________________________________ FAX NO. __________________________________

IS THE EMPLOYER A BROKER DEALER: ( ) YES ( ) NO

NAME OF ATTORNEY-IN-FACT, IF APPLICABLE: _____________________________________________________________________

OFFICER OR DIRECTOR OF AN EXCHANGE-LISTED COMPANY: ( ) YES ( ) NO

CUSTOMER REFERRED BY: ________________________________________________ CUSTOMER’S BANK: _____________________________________

HOW LONG KNOWN BY SALESMAN INTRODUCING ACCOUNT: ______________________________ SOURCES OF FUNDS: _______________________________

INVESTMENT OBJECTIVES: ( ) SPECULATION ( ) GROWTH

( ) PRESERVATION OF CAPITAL ( ) LONG TERM INVESTMENT ( ) ALL OF THE ABOVE

ANNUAL INCOME: ASSETS: NET WORTH:

NAME: ___________________________________________________ BIRTH DATE: ____________________________________________________

NATIONALITY: ____________________________________________________ BIRTH PLACE: ____________________________________________________

TIN NO. : ______________________________________________________ SSS / GSIS NO. : ____________________________________________________

NAME OF SPOUSE: ___________________________________________

RESIDENCE ADDRESS: ________________________________________________________ RES. TELEPHONE NO.. ________________________________________

_________________________________________________________________________________ FAX NO.. ________________________________________

OCCUPATION: ____________________________________________ EMPLOYER: ____________________________________________________

BUSINESS ADDRESS: __________________________________________________________ OFC. TELEPHONE NO. ____________________________________.

_________________________________________________________________________________ FAX NO. __________________________________

IS THE EMPLOYER A BROKER DEALER: ( ) YES ( ) NO

NAME OF ATTORNEY-IN-FACT, IF APPLICABLE: _____________________________________________________________________

OFFICER OR DIRECTOR OF AN EXCHANGE-LISTED COMPANY: ( ) YES ( ) NO

CUSTOMER REFERRED BY: ________________________________________________ CUSTOMER’S BANK ______________________________________

HOW LONG KNOWN BY SALESMAN INTRODUCING ACCOUNT: ______________________________ SOURCES OF FUNDS: ________________________________

INVESTMENT OBJECTIVES: ( ) SPECULATION ( ) GROWTH

( ) PRESERVATION OF CAPITAL ( ) LONG TERM INVESTMENT ( ) ALL OF THE ABOVE

ANNUAL INCOME: ASSETS: NET WORTH:

ARE DUPLICATE CONFIRMATION REQUIRED? ( ) YES ( ) NO

IF YES, IDENTIFY TO WHOM TO BE SENT AND RELATIONSHIP TO THE CUSTOMER: ________________________________________________________

ADDRESS: ______________________________________________________________ TELEPHONE NO.: _____________________________________________

MANNER OF SENDING CONFIRMATION: ( ) COURIER ( ) FACSIMILE ( ) ELECTRONICALLY (via e-mail) ( ) IN – HOUSE MESSENGER

DO YOU HAVE AN ACCOUNT WITH OTHER BROKER/DEALER: ( ) YES ( ) NO

NAME OF BROKER/DEALER: ________________________________________________

_________________________________________________________________ ___________________________________________________________
SIGNATURE OF CUSTOMER OR ATTORNEY-IN-FACT DATE

_________________________________________________________________ ___________________________________________________________
SIGNATURE OF AUTHORIZED PERSON TO EXERCISE DATE
DISCRETION

_________________________________________________________________ ___________________________________________________________
SIGNATURE OF SALESMAN INTRODUCING THE ACCOUNT DATE

_________________________________________________________________ ___________________________________________________________
SIGNATURE OF OFFICER/MANAGER ACCEPTING DATE
THE ACCOUNT
FOR EVERGREEN STOCK BROKERAGE & SECURITIES, INC. USE ONLY (PLS. DO NOT FILL UP)

APPROVED BY: ___________________________________________ DATE: ___________________________________________________________________