MEMBER INFORMATION DATA SHEET

ONLINE MEMBERSHIP APPLICATION

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MEMBER INFORMATION DATA SHEET

Mandaue City Public Market Vendors Multi-purpose Cooperative-MAVENCO Suson Street Centro Mandaue City 6014 Telephone no. 420-1872 | 2396017 CDA REGISTER NO. 9520-07001813
Instructions
a. Fill up the form. All fields must be filled out completely as required by RA 9510.
b. Please fill up clearly in BLOCK or CAPITAL LETTERS and affix signatures
c. Do not leave any field blank. Indicate N/A when applicable.

	New Member	For Updating	Regular	Associate
Member

Client | Member Name*

PrefixFirst NameMiddle NameLast NameSuffix
Father Name*

PrefixFirst NameMiddle NameLast NameSuffix
Mother Maiden Name*

PrefixFirst NameMiddle NameLast NameSuffix
Spouse Name if Married*

PrefixFirst NameMiddle NameLast NameSuffix
Spouse Other Details*

Date Of BirthEducational AttainmentGenderOccupation
Date of Birth*

MonthDayYear
Member Date of Birth
Place of Birth
Gender
Civi Status
Religious Affiliation
Educational Attainment
Sectoral Group
Occupation
Height (CM)
Weight (Kgs)

Primary Identification
I.D Number
Secondary Identification
In the absence of Primary I.D Answer this Dropdown
I.D Number
Current Residence Address*

Unit Room Building No. Lot No./Block No./House No. Street Name Subdivision

Barangay Municipality/City Province Postal Code

CityState / Province | Postal Code

Since Resindence MM/DD/YYYYCountry
Current Provincial Address*

Unit Room Building No. Lot No./Block No./House No. Street Name Subdivision

Barangay Municipality/City Province Postal Code

CityState / Province | Postal Code

Since Residence MM/DD/yyyyCountry
Home Phone Number

Country CodeArea CodePhone Number
Mobile Number*
Please enter a valid phone number.

Beneficiaries

First NameMiddle NameLast NameRelationDate of Birth
Beneficiaries

First NameMiddle NameLast NameRelationDate of Birth
Beneficiaries

First NameMiddle NameLast NameRelationDate of Birth
Beneficiaries

First NameMiddle NameLast NameRelationDate of Birth

Declaration and Specimen Signature

1. I, whose specimen signature appears below, confirm that all the information disclosed in this Member information data sheet is correct and complete. Any changes in the foregoing information shall be communicated to the Company. I hereby authorize the Company to verify and investigate any and all information given by me which the Company may deem appropriate.

2. I hereby acknowledge and authorize the Company: 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; 2) the sharing of my basic credit data with other lenders authorized by the CIC, and credit reporting agencies duly accredited by the CIC.
Signature*

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Spicemen
Signature*

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Spicemen
Signature*

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Referred By: First Name Last Name Phone Number Email

SUBSCRIPTION AGREEMENT
This SUBSCRIPTION AGREEMENT entered into by and between:The Mandaue City Public Market Vendors Multi-purpose Cooperative – MAVENCO, cooperative duly registered with the Cooperative Development Authority (CDA), with principal offices at Suson Street Centro Mandaue City, herein represented by its Chairperson Luisita O. Valdueza , hereinafter referred to as the FIRST PARTY,and{client} of legal age, single/married, Filipino citizen and a resident of {placeOf} , Philippines, hereinafter referred to as the SECOND PARTY,

WHEREAS; the FIRST PARTY is a cooperative organization and is authorized by the Cooperative Development Authority (CDA) to issue share certificates to its owner-members, as authorized by the Cooperative Code of the Philippines, to indicate their share and participation in the ownership of the said primary cooperative;

WHEREAS; the SECOND PARTY is not prohibited by the By-laws of the cooperative to become a member and acquire shares of the said cooperative;

WHEREAS; upon resolution of its Board of Directors the SECOND PARTY, whose application for membership with the FIRST PARTY have already been approved by the Board of Directors, would like to subscribe to shares of the FIRST PARTY;

WHEREFORE; the FIRST PARTY hereby accepts the application for subscription and hereby sells its own shares to the SECOND PARTY under the following terms and conditions, to wit:
1.Kinds of Share Subscribed:
2.Number of Shares Subscribed
3.Par Value of Shares
4.Total Value of Shares Subscribed
4.Total Value of Shares Subscribed
5.Amount of Shares
5.Amount initially paid for said subscription (at least 25% of total subscribed shares, which was originally deposited upon filing of application for membership)
6.Equal Monthly Installement
6.Balance of: will be paid on equal monthly installment of
7.Date of Payment

MonthDayYear
Payment of unpaid balance will begin on (date above) and on the same date every month thereafter until the whole amount is fully paid.
8.2% interest per month or a fraction thereof, will be charged for unpaid subscription installment.

9.Share certificates covering this particular subscription agreement will be issued by the FIRST PARTY to the SECOND PARTY upon full payment of the unpaid balance. 10. All paid shares that reached the qualification for voting, even if the corresponding share certificate have not as yet been actually issued, will be entitled to dividends.
In witness whereof, the parties have hereto affixed their signatures this blanks day of blank , Philppines.
First Party
By Chairperson
Second Party
By Member
(ACKNOWLEDGMENT)
REPUBLIC OF THE PHILIPPINES)

__________________________
Before me, the undersigned notary public and for the on thisblanks day of blank ,201 personally appeared affiant(s) with residence certificate number(s),
known to be one and the same person(s) whose name(s) is (area) subscribed and who executed the foregoing instruments and acknowledge to me that he/she/they signed and executed the same as an act of his/her/their free will and deed, for the uses and purpose therein set forth. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal at the place and on the date first hereinabove written.
Mavenco Cooperative
Should be Empty:

ONLINE MEMBERSHIP APPLICATION

MEMBER INFORMATION DATA SHEET

SUBSCRIPTION AGREEMENT

(ACKNOWLEDGMENT)