Application for Associate Membership

Application for Associate Membership
Date

MonthDayYear
Date
Branch/Satellite Office*
Type of Account*
- Title*
- Name of Applicant*
  
  First NameMiddle NameLast NameSuffix (e.g. Jr, Sr)
- Birthdate*
  
  MonthDayYear
  Date
- Birthplace
- Male (M)Female (F)
- Age*
- Address*
  
  House No./Purok/Street Address
  
  Barangay
  
  City/MunicipalityState / Province
  
  Postal / Zip Code
- Contact Number*
  Format: (000) 000-0000.
- Email Address
  example@example.com
- Civil Status*
- Nationality*
- Alien Reg. Certificate No.
- Occupation*
- Monthly Income (Php)
- Spouse Name
  
  First NameMiddle NameLast NameSuffix
- Upload a photo or selfie for your 2x2 photo preferably with a white background (Make sure not to cover any part of your face and remember to position your head / face properly in the camera capture frame)
  
  Cancelof
- Valid ID (front side)
  
  Cancelof
- Valid ID (back side)
  
  Cancelof
- Title*
- Name of Applicant*
  
  First NameMiddle NameLast NameSuffix (e.g. Jr, Sr)
- Birthdate*
  
  MonthDayYear
  Date
- Birthplace
- Male (M)Female (F)
- Age*
- Address*
  
  House No./Purok/Street Address
  
  Barangay
  
  City/MunicipalityState / Province
  
  Postal / Zip Code
- Contact Number*
  Format: (000) 000-0000.
- Email Address
  example@example.com
- Civil Status*
- Nationality*
- Occupation*
- Monthly Income (Php)
- Spouse Name
  
  First NameMiddle NameLast NameSuffix
- Upload a photo or selfie for your 2x2 photo preferably with a white background (Make sure not to cover any part of your face and remember to position your head / face properly in the camera capture frame)
  
  Cancelof
- Valid ID (front side)
  
  Cancelof
- Valid ID (back side)
  
  Cancelof
- Name of Beneficiary 1*
  
  First NameMiddle NameLast NameSuffix
- Date of Birth
  
  MonthDayYear
  Date
- Relationship
- Name of Beneficiary 2
  
  First NameMiddle NameLast NameSuffix
- Date of Birth
  
  MonthDayYear
  Date
- Relationship
- Name of Beneficiary 3
  
  First NameMiddle NameLast NameSuffix
- Date of Birth
  
  MonthDayYear
  Date
- Relationship

TERMS AND CONDITIONS
First NameMiddle NameLast NameSuffix
Signature
Date

MonthDayYear
Date
First NameMiddle NameLast NameSuffix
Signature
Date

MonthDayYear
Date
- I/We hereby apply for Associate Membership in the Gubat St. Anthony Cooperative of Gubat, Sorsogon this {date}. I/We agree to obey faithfully the rules and regulations stipulated in its Articles of Cooperation and By-Laws and amendments thereof, the decision of the General Assembly as well as those of the Board of Directors.
  
  Furthermore, I/we hereby pledge to do the following:
  1. Pay the required membership fee;
  2. Support and participate in the Capital Build-Up (CBU) scheme of the cooperative for its internal fund generation;
  3. That after two (2) years of continuously patronizing any of the services of the cooperative and have met the minimum requirements of regular membership I will be considered as regular member. (for Individual Account only)
- I/We hereby warrant the truth, accuracy, completeness, and authenticity of all data/information furnished herein as of the date of this application submission to the best of my/our knowledge. Any misdeclaration hereto will automatically cause the disapproval of this application.
- In accordance with RA 10173, also known as "Data Privacy Act of 2012":
  
  I/We hereby allow GUBAT ST. ANTHONY COOPERATIVE ("Cooperative") to provide me/us certain service declared in the forms where this Data Privacy Consent Form is attached.
  
  I/We hereby acknowledge that I/we have the consent of all parties pertinent to this transaction to disclose their information for the proper administration and provision of services requested from this transaction.
  
  I/We hereby hold free and harmless and undertake to indemnify the Cooperative for any complaint, suit, damages, and the like which any party may file or claim against the Cooperative in relation to this acknowledgment and warranty.
  
  I/We agree to the terms and conditions contained in this Data Privacy Consent Form.
- The undersigned {nameOf} and/or {nameOf281} joint depositors. Hereby agree each with the other and with the Gubat St. Anthony Cooperative that the sum now on deposit heretofore or hereafter deposited by either or both of said depositors, with said Cooperative to their credit as such joint depositors with all accumulation thereon are and shall be owned by them jointly, with right of survivorship, and be subject to the order of receipt of either of them or their survivors and payment to or on the order of either or the survivor shall be valid and discharge said Cooperative liability.
  
  Both of the undersigned appoints the other attorney, with the power to deposit in said joint account the money of the owner and for that purpose to endorse any check, draft, note or other instruments payable to the order of the other or both said joint depositors.
  
  The Rights or authority of the Cooperative under the agreement shall not be changed or terminated by said depositors or either of them except by written notice to the Cooperative which shall not affect transactions therefore made.

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(to be filled-out by GSAC employee)

Application Status:

[ ] Approved

[ ] Pending

[ ] Disapproved


Reccomending Approval:
	Branch Manager/Loan Supervisor


Approved by:
	EDCOM Chairperson


Associate Membership No:
Registration Date:

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Application for Associate Membership

TERMS AND CONDITIONS