<p>Central Bank of Oman (Bank Credit and Statistical Bureau) Evidence Credit Information Report (ECIR) Form Please ensure that the information provided in the spaces indicated below is legible. Any ECIR form received after 30 days of loan application shall not be entertained Entity Details (This information is necessary to identify the entity raising the request for an Evidence CIR. Please note that the information being provided should be in CAPITAL LETTERS Only.)</p><p>* - Mandatory Fields Name </p><p>Borrower Type* Individual Entity Borrower Name* Identifiers Date of Birth / Registration * Gender (DD-MMM-YYYY) Nationality </p><p>Civil ID Resident ID Passport Number Identifier Type* CRN Bureau Assigned Number (for Non MOCI)</p><p>Identification Number * Loan Details Amount of Loan Requested* Currency of Requested Loan* Facility/Loan Type* (for instance, Housing Loan, Personal Loan) Contact Details (as provided to the Member Institution/ others)</p><p>Mailing Address (Please provide only Oman Address)*</p><p>Telephone / GSM Number URL Email ID</p><p>PUBLIC Declaration by the Customer I/We ______, wish to request for an Evidence Credit Information Report (ECIR). I/We hereby declare that all the information furnished above is true and accurate and documents attached are genuine and true copies. I/We am/are aware of the provisions of the Central Bank of Oman (CBO). I/We am/are also aware that all the information enclosed above will be subject to further scrutiny by CBO. Date (DD-MMM-YYYY):Ex. 12-Jan-2009</p><p>Signature: Company Stamp:</p><p>NOTE: All corporate entities are to provide a letter of authorization providing details of the person representing the entity. A copy of the ECIR shall be given only to the person specified as the representative (after verifying the identity). The form and the letter should contain the company stamp.</p><p>Office Use Only ECIR Filed Date* DD-MMM-YYYY Credit Information Report Number* Proof Receipt Details (Please Tick) </p><p>ID copy (Civil ID /Resident ID / Passport) Yes No</p><p>Proof of Authorized Signatory Yes No</p><p>Proof of Entity Registration Yes No Authorized Officer / User </p><p>Signature </p><p>PUBLIC</p>