Application Form No. 16

UPLBCDC Form No.
16
Revised April 2018
UPLB CREDIT AND DEVELOPMENT COOPERATIVE
Sacay Grand Villas, Kanluran Road, College, Laguna
Tel. No. (Main: 501-2059/ 536-3638/536-2830/536-2263) (Branch: 536-7668/536-2949)
(NAME)
REQUIREMENTS
1 Pre- Membership Education Seminar (PMES):

Date:
2 Medical Examinations
Accredited Hospitals: University Health Service (536-3247/2470)
Los Baños Doctors Hospital (536-0100/1825)
Bio-Scan Clinic Laboratory (536-4875)
Medical Certificate
s Lab Test Results
Medical Evaluation Form
3. Documents Required
3 pcs. (1x1) Recent ID Picture
Barangay / Police/ NBI Clearance
Birth Certificate (Applicant)
Certificate of Attendance (Pre- Membership Education Seminar)
Evaluation Form
Application Form
Sketch of Residence
LEGAL BENEFICIARY (IES)
Spouse- Marriage Contract
Child- Birth Certificate of Child
Parents- Birth Certificate of Applicant
Brother/Sister – Birth Certificate of Brother/ Sister
4. EMPLOYMENT REQUIREMENTS
SELF-EMPLOYED
BUSINESS
Photocopy of DTI and Barangay/Mayor’s Permit
Sketch of Business Location
Affidavit of Income
TRANSPORT OPERATORS
Photocopy of OR/CR and franchise permit name of applicant
Affidavit of Income
NOTE: All original copies must be presented for authentication

EMPLOYED
Local (within the country)
Photocopy of latest appointment/certificate of employment
Photocopy of Renewal of Appointment (for non-permanent/non-regular employee)
Latest pay slip, payroll, voucher or pay envelope
Overseas Filipino Worker (OFW)
Photocopy of Passport and Visa
Photocopy of latest appointment/contract
General or Special Power of Attorney
1. Are you presently a member of a cooperative? Yes No

If yes, state the name of cooperative
2. Please check if you are a New Applicant Returning Member

If returning member, please state reason of separation from the cooperative
3. Within the last five years, have you been confirmed in a hospital and/or received medical or surgical
advice or attention? Yes No
If yes, give details and dates
4. Have you ever had or consulted a physician for a heart condition, diabetes, lung, high blood pressure,
cancer, kidney or stomach disorder or any physical impairment? Yes No
If yes, give details and dates
5. To the best of your knowledge, are you now in good health? Yes No
I hereby declare and agree that all the foregoing answers and statements are complete, true
and correct to the best of my knowledge and belief. I hereby agree that if there be any fraud or
misinterpretation in the above statement, cooperative shall have the right to declare my membership
null and void.
Signature
I hereby apply for membership in the UPLB CREDIT AND DEVELOPMENT COOPERATIVE. I agree to obey
faithfully its rules and regulations as stipulated in its Articles of Cooperation and By-Laws, the decisions of the
general membership and those of the Board of Directors.
Thereby pledge to:
1. Attend and complete the prescribed Pre-Membership Education Seminar (PMES).
2. Pay the membership fee of 100.00.
3. Participate in the following capital build-up program.
a. Subscribe for at least __________ minimum share capital and pay them either in lumpsum or
installment, under the terms and conditions prescribed in the Membership Agreement.
b. Contribute at least 1% of every loan granted me.
Signature or Right Thumb mark of Applicant Endorsed by: Printed Name & Signature
Contact Number/s:
PERSONAL DATA (PLEASE PRINT)
NAME: CIVIL STATUS: SEX:

BIRTHPLACE: BIRTHDATE: EDUCATIONAL ATTAINMENT:
PRESENT ADDRESS:
(House No./ Blk & Lot/Phase/Street/Subdivision)
Tel no.
(Barangay) (City/ Municipality) (Province) (Zipcode)
PERMANENT ADDRESS:
(House No./ Blk & Lot/Phase/Street/Subdivision)
Tel no.
(Barangay) (City/ Municipality) (Province) (Zipcode)
OFFICE/ BUSINESS NAME: Tel no.
OFFICE/BUSINESS ADDRESS:
OCCUPATION/POSITION:
MONTHLY INCOME: Php MONTHLY ALLOWANCE Php
STATUS OF APPOINTMENT:
PERMANENT PROBATIONARY/ TEMPORARY CONTRACTUAL/CASUAL EMERGENCY
OTHER SOURCES OF INCOME:
LEGAL BENEFICIARY (IES): RELATIONSHIP
RELATIONSHIP
RELATIONSHIP
RELATIONSHIP
RELATIONSHIP
Specimen Signature of Spouse:
Recommended By:
Chairman, Education & Training Committee
This application for membership was approved/disapproved by the Board of Directors in its meeting
held on , 20
PASSBOOK NO.
DATE: Secretary
EARN AND SAVE THE COOPERATIVE WAY

Application Form No. 16

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UPLBCDC Form No.

1 Pre- Membership Education Seminar (PMES):

NOTE: All original copies must be presented for authentication

1. Are you presently a member of a cooperative? Yes No

2. Please check if you are a New Applicant Returning Member

NAME: CIVIL STATUS: SEX:

Chairman, Education & Training Committee

EARN AND SAVE THE COOPERATIVE WAY

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