PAGLAUM MULTI-PURPOSE COOPERATIVE

Head Office: 2F Eastern Looc, Plaridel, Misamis Occidental Tel # (088) 344-8633
CDA Reg. No. CGY-976
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MEMBERSHIP FORM

Date:__________________

1. Name ______________________________________________________________________
(FAMILY NAME) (GIVEN NAME) (MIDDLE NAME)

Date of Birth:_______________ Birth Place:___________ Civil Status:_________

Religion:___________________ Sex:________________ Tribe:______________
SSS/GSIS No.________________ TIN No.____________ Postal Code__________
Address: __________________________________________________________
Business/Office Address:______________________________________________
2. Beneficiary/ies in case of emergency / death:
Spouse:_________________ Birth Date:_________ Contact No.______________
Children:________________ Birth Date:_________ Contact No.______________
_________________ Birth Date:_________ Contact No.______________
_________________ Birth Date:_________ Contact No.______________
Others : ________________ Relationship:________Contact No.______________
_________________ Relationship:________Contact No.______________
3. Educational Attainment: ______________________________________________
4. Present Employment/ Business Activities:___________________________________

OCCUPATION : ( ) Private Employee ( ) Gov’t Employee ( ) Self-Employed ( ) Farmer

( ) Pensioner ( ) Student ( ) Housekeeper ( ) Fisherfolk
( ) Entrepreneur/ Vendor ( ) Others ________________

MONTHLY INCOME: ( ) 0-999 ( ) 2,000-2,999 ( ) 4,000-4,999 ( ) 10,000-15,000

( ) 1,000-1,999 ( ) 3,000-3,999 ( ) 5,000-9,999 ( ) 15,000 +

I hereby certify that the above information is true and correct.

Signed this_____ day of ______________,_______.

________________________________
Signature
Endorsed by: ____________________