PHOTO

DEPED SALARY LOAN APPLICATION FORM

Date of Application:

LAST NAME FIRST NAME MIDDLE NAME

EMAIL ADDRESS: @deped.gov.ph SEX: MALE FEMALE

PRESENT ADDRESS: _

PERMANENT ADDRESS:

MOBILE NO.: BIRTHDAY: AGE: CIVIL STATUS: NO. OF DEPENDENTS:

SCHOOL NAME:

SCHOOL ADDRESS:

DIVISION CODE: STATION CODE: EMPLOYEE NO.: TIN NO.:

EMPLOYMENT STATUS: POSITION: DATE HIRED:

OTHER SOURCE OF INCOME: AMOUNT: ₱

LOAN PURPOSE: ( Check One Below)

Agricultural Major Car Repair House Repair Tuition Fee Purchase of Appliances

Hospitalization Others (Pls. Specify)

LOAN AMOUNT ₱ LOAN DEDUCTION ₱ LOAN TERM mos.

In connection with my loan application, I hereby acknowledge and authorize:

1) the regular submission and disclosure of my basic credit data (as defined under Republic Act No. 9510 and its implementing
rules and regulations) to the Credit Information Corporation (CIC), as well as any updates or corrections thereof; and
2) the sharing of my basic credit data with other lenders authorized by the CIC, and credit reporting agencies duly accredited by
the CIC.

AGREEMENT:
I/We affirm that each of the statement made in this application is true and correct and agree to notify the bank of any material change
affecting the information contained herein. I/We authorized you to obtain and verify such information as may be required covering this application.
You may approve or reject my/our application at your sole discretion. I/We understand that should my/our application be denied, Wealthbank has
no obligation on its part to furnish the reason on such rejection. Furthermore, I/We agree that all information obtained by Wealthbank shall remain
its property whether or not the loan is granted.

BORROWER: CO-MAKER:

(Signature over Printed Name/Date) (Signature over Printed Name/Date)

CO-MAKER INFO:
REQUIREMENTS:
Borrower Requirements: Present Address:
2 pcs. 2X2 Picture (For New Loans Only)
Fully filled up DepEd Application Form Permanent Address:
Photocopy of 2 Valid ID (PRC, DEPED, GSIS or School ID) Civil Status No. of Dependents:
with 3 specimen signature
Certified True Copy of Appointment or Service Record Birthday: Cellphone No:
Latest ORIGINAL Payslip TIN Number: Position:
Co-Maker Requirement:
School Name:
Photocopy of 1 Valid ID (PRC, DEPED, GSIS or School ID)
with 3 specimen signature. School Address:
Buy-Out: Latest Statement of Account Division Code: Station Code: Employee No.:
Government / School ID No.: Date Hired:

For Bank Use Only

ANY UPCOMING PLI LOAN DEDUCTION? YES NO IF YES, INDICATE PLI’s NAME: AMOUNT: ₱

GSIS CONFIRMATION
Name of Agent :
Date :
Time :
TYPE OF LOAN:
ANY UPCOMING GSIS LOAN YES NO
New Loan IF YES, Check box below
AMORTIZATION / DEDUCTION
Reloan CONSOLIDATED : ______________ _____________
EMERGENCY : ______________ _____________
EDUCATIONAL : ______________ _____________
Sales Officer: REGULAR POLICY : ______________ _____________
GFAL : ______________ _____________
 ---Back Page---

ADDITIONAL INFORMATION FOR GSIS CONFIRMATION:

BP NUMBER: ___________________________________

CRN NUMBER: __________________________________

PLACE OF BIRTH: _______________________________

FATHER’S LAST NAME FIRST NAME MIDDLE NAME

____________________________________ _______________________________________ __________________________________________

MOTHER’S MAIDEN NAME FIRST NAME MIDDLE NAME

____________________________________ _______________________________________ __________________________________________

SPOUSE NAME: ________________________________ SPOUSE OCCUPATION: ____________________________________

BIRTHDAY: _______________________ SPOUSE EMPLOYER / BUSINESS NAME: __________________________________