PERSONAL DATA Name Address Province/City Telephone Number Fax Number PROPOSED LOCATION Address Province/City Lot Size (sqm) Frontage (meters) I am interested in: One Product - One Dispenser (Filling Station) Gasolinahang Bayan with Toilet & Equipment room - 3 Products, 2 - 3 Dispensers Gasolinahang Bayan - Single Island with C-Store and other Amenities Gasoline Station - at least 2-Pump Islands with minimal Amenities Gasoline Station - at least 2-Pump Islands with C-Store and Amenities Full Service Station - at least 3-Pump Islands with Mechanical Bays and C-Store To facilitate processing of your application, please submit the following with your completed application form. • Site Drawing of Location Map • Picture of Site • Title Copy of the Prospective Property (Photocopy of TCT) • Completed Market Survey Sheet of the Location Please submit the following information to: 7th Floor, Cityland Pasong Tamo Tower, Km. 8, 2210 Don Chino Roces Avenue, Pio Del Pilar, Makati City This form when completed is an essential part of our consideration in granting a franchise license to you. All answers are held in confidence. The completion of this form does not obligate Eastern Petroleum or YOU in any way or manner.