AUTOSWEEP RFID SUBSCRIPTION FORM

(PERSONAL)
CUSTOMER INFORMATION

Title

Given Name

Middle Name

Last Name

Nick Name

House & Bldg. No.

Street

Village/Subdivision

City/Municipality

Provice & Zip Code

Landline No.

Fax No.

Mobile No. 1

Mobile No. 2

Mobile No. 3

ID No.

TIN

CONTACT INFORMATION

Other Informations
ID Presented

Email Address

OTHER CONTACT DETAILS (In case of Emergency)

Complete Name

Relationship

Contact No (Landline)

Contact No (Mobile)

Year & Color

Remarks

VEHICLE INFORMATION

Registered Owner
Class

Not the Registered Owner (User Only)

Plate No

Make & Model

I hereby certify that the information provided above is true, correct and complete. I voluntarily disclose my personal information for the
fulfilment of my Autosweep RFID account management. I understand that any false, misleading, incorrect or withheld information may cause the
disapproval or termination of the contract for the Autosweep RFID Services.
____________________________

__________________________

__________________

Customer's Printed Name

Signature

Date

TO BE FILLED UP BY Autosweep RFID REPRESENTATIVE

Processed By
POS Location

POS Name & Signature

REMARKS (If Any)

Requirements Checklist
c Subscription Form
c Signed T&C Vehicle OR & CR
c 1-Valid ID
c Authorization letter (if not the registered owner)
c ID of the Registered Owner

Autosweep RFID Account No.

Date Issued