Membership Application

Member's Personal Data

Branch*

Last Name*

First Name*

Middle Name*

Day of Birth*

Place of Birth*

Religion*

Age*

Gender*

Male
Female

Height (cm)*

Weight (kg)*

Address*

Zip Code*

Email*

Contact Number(s)*

Tax Identification Number*

Civil Status*

Single
Married
Separated
Widowed

VALID/GOVERNMENT ISSUED IDS

ID Type*

ID Number*

ID Type

ID Number

Educational Attainment*

Graduate?*

Yes
No

Graduate?*

Yes
No

Graduate?*

Yes
No

Degree*

Graduate?*

Yes
No

Degree*

Graduate?*

Yes
No

Degree*

Occupation*

IF EMPLOYED

Status*

Permanent
Contractual
Temporary

Employer Name*

Employer Address*

Annual Income*

IF SELF-EMPLOYED

Business Name

Business Address

Contact Number(s)

Annual Income

Family Profile

Household Member's Name*

Relationship*

Date of Birth*

Age*

Occupation

Employer

Annual Income

Barbaza MPC Member*

Yes
No

Add Household Member

Household Member's Name (2)*

Relationship*

Date of Birth*

Age*

Occupation

Employer

Annual Income

Barbaza MPC Member*

Yes
No

Add Household Member

Household Member's Name (3)*

Relationship*

Date of Birth*

Age*

Occupation

Employer

Annual Income

Barbaza MPC Member*

Yes
No

Add Household Member

Household Member's Name (4)*

Relationship*

Date of Birth*

Age*

Occupation

Employer

Annual Income

Barbaza MPC Member*

Yes
No

Add Household Member

Household Member's Name (5)*

Relationship*

Date of Birth*

Age*

Occupation

Employer

Annual Income

Barbaza MPC Member*

Yes
No

Real/Personal Property Owned

Note: if not applicable put NA or None.

Description

Residential
Commercial
Industrial
Agricultural

Land Title Number

Lot Number

Location

Lot Area (sqm)

Agriculture

Rice
Corn
Sugarcane
Coconut
Others

Specify

Add Real Property

Description

Residential
Commercial
Industrial
Agricultural

Land Title Number

Lot Number

Location

Lot Area (sqm)

Agriculture

Rice
Corn
Sugarcane
Coconut
Others

Specify

Vehicle Owned

Car
Motorcycle
Tricycle
Others

Specify

Beneficiaries

Beneficiary Name*

Relationship*

Date of Birth*

Add Beneficiary

Beneficiary Name

Relationship

Date of Birth

Add Beneficiary

Beneficiary Name

Relationship

Date of Birth

Occupational and Special Skills

Farming

Palay
Corn
Vegetable
Others

Specify

Fishing

Fishing

Livestock

Swine
Poultry
Others

Specify

Construction

Masonry
Carpentry
Plumbing
Electrical
Painting
Others

Specify

Processing

Food Processing
Preservation
Others

Specify

Servicing

Cosmetology
Massage Therapist
Mechanical Repair
Electronics
Appliance Repair
Others

Specify

Craft

Furniture Making
Metal Work
Tailoring
Others

Specify

Other Occupations and Special Skills

Membership in other Cooperatives

Cooperative Name

Cooperative Address

Add Cooperative

Add Cooperative

Cooperative Name

Cooperative Address

MEMBER’S SUBSCRIPTION AGREEMENT

Common Shares - represents the share in the ownership position of the Cooperative which gives right to receive dividends and right to vote and participate in the general meetings of the cooperative.

Preferred shares - is a share which enjoys priority in receiving dividends as compared to common stock and do not enjoy voting rights.

The Board of Directors,

In connection with my membership to this Cooperative, I hereby subscribe at least 100

Number of Shares*

Share*

Common
Preferred

Shares valued at One Hundred Pesos (Php100.00) per share or equivalent to Ten Thousand Pesos (Php 10,000.00), on the following terms and conditions:

Pesos*

1. I agree to pay the initial amount of at least Five Hundred (Php500.00) Pesos upon subscription

and the balance to be paid in installment of Php

Installment of*

, payable within

Months*

years (but not to exceed in 60 months).

I agree that the unpaid balance of my subscribed capital is my liability to this Cooperative.

2. I agree that I could guarantee/sell a portion of my share capital to any member with prior approval by the Cooperative. I agree that I could make claims to my share capital contribution upon termination of membership without pending obligation and subject to the Cooperative applicable policies, systems and procedures.

3. To participate in the planned thrift and savings program by depositing at least Five Hundred Pesos (Php500.00)

as my initial savings deposit and at least Php

Installment of*

every month thereafter.

UNDERTAKING

Consent

I hereby certify that all information herein and herewith furnished are all in respects true and correct and submitted for the purpose of application of membership to Barbaza Multi-Purpose Cooperative. It is also agreed that the Cooperative may inquire into their correctness by the methods it may deem proper to use and that this document shall remain the property of Barbaza Multi-Purpose Cooperative whether or not the membership application is approved or disapproved by the Board of Directors.

Attachment

Write down your signature in a piece of white paper, take a photo, crop accordingly before uploading. See Example

Signature*

Drop files here or

Accepts *.jpeg, *.jpg, *.png and max. file size of 20mb.

Upload a picture of 1 Government Issued IDs placed on top of a white piece of paper with 3 signatures. See Example

Valid and acceptable IDS. See Example

GOVERNMENT ID

ID Front Side*

Drop files here or

Accepts *.jpeg, *.jpg, *.png and max. file size of 20mb.

ID Back Side*

Drop files here or

Accepts *.jpeg, *.jpg, *.png and max. file size of 20mb.

Name

This field is for validation purposes and should be left unchanged.

Membership Application