DAVAO PENINSULA FARMERS CREDIT COOPERATIVE

CDA Reg. No.: 9520-1011000000026927

Purok 6, Quiambao Compound, Magsaysay St., Calinan, Davao City
Tel No. (082) 2957290

LOAN APPLICATION FORM

(PLEASE PRINT DATA TO FILL-UP THE FORM)

(THIS FORM IS NOT FOR SALE)

Application Date: ______________________

Application No: _______________

Date Received: ________________________

_________________________

Recruiting Coop Officer/Member:

PERSONAL DETAILS
Gender: Male Female

Name: Mr. Mrs. Ms

First

Middle

Last

Date of Birth: (MM/DD/YYYY)

Nationality:

___/___/_____

Filipino Others (specify) _________

Place of Birth:

Religion: __________________

________________________

Number of Dependents: _______________

Civil Status: Single

Married

SSS/GSIS Number:

Legally Separated

Tax Identification Number:

___________________

________________________

Annulled

Widowed

Other IDs:
________________________

Name of Nearest Neighbor: _______________________________

Who recommended you to the coop? ___________________________
Address: _________________________________________________ Contact No.: ___________________
Health Conditions:
Blood Type: A

AB

Others (specify)

Physical Disabilities:

___________________
Undergoing

Medical

Treatments

at

present?

Yes

No

(if

yes,

specify)

________________________________________

When:

_____________________________________
Details

of

last

hospital

confinement:

_______________________
In

case

of

emergency,

contact

person:

________________________________________

No.:

________________________
Interested

to

open

business

venture?

Yes

No

(if

yes,

__________________________________________
Knowledgeable in the said business? Yes No
Directory listing yes no

specify)

Family Members:
Name

Relationshi
p

Educational Background:
Level

Ag
e

Employmen
t

Name of School

Ave.
Monthly
Income

Already
a Coop
Member?
(YES /
NO)

Course

Living in
the same
househol
d?
(YES /
NO)

Year
Graduated

Elementary
High School
Technical School
College
Post Graduate
CONTACT DETAILS
Present

Address:

Zip Code:
______________________________________________________________________________________________
St. No.

St. Name

_______

Barangay

City

Length of Stay in Present Address: _______ years _______ months

Present Residence Type: Owned

Living with Parents

Mortgaged (specify) _____________

Rented (Monthly Rent) ______________ Others (specify) __________________________

Certified by Recruiting Coop Officer/Member:
___________________________________________________

________________________

Name & Signature of Recruiting Coop Officer/Member

Date

Previous

Address:

Zip Code:
_____________________________________________________________________________________________ __________
No.

St. Name

Barangay

City

Length of Stay in Previous Address: _______ years _______ months

Previous Residence Type: Owned

Living with Parents

Mortgaged (specify) _________________

Rented (Monthly Rent) ____________ Others (specify) _____________________________

Provincial

Address/Permanent

Address

(if

applicable):

Zip Code
_____________________________________________________________________________________________
St. No.

St. Name

__________

Barangay

City

Length of Stay in Permanent Address: _______ years _______ months

Residence Type: Owned

Living with Parents

Rented (Mo. Rent) ___________

Others (specify) _____________________________

Home Phone Number:

Mobile Number:

_____________________________
Home Phone Type:

Mortgaged (specify) _______________________

__________________________

Mobile Phone Type:

Prepaid

Email Address:

___________________________________________

Mailing Address:

Postpaid

Prepaid

Postpaid

___________________________________________________________
St

. No.

St. Name

Barangay

City

EMPLOYMENT DETAILS
SELF-EMPLOYED

EMPLOYED

UNEMPLOYED

Employer/Business Name:

Name of Business:

housewife

_________________________________________

_________________________________________

Office Address:

Type of Business:

student

_________________________________________

Sole Prop Partnership Corp

Nature

Nature

of

Business:

_______________________
Office

No:

of

Others (specify) ____________________

_______________________

______________Fax

No.:

_________

Asset

Size

of

Business

(Php):

_______________

Employment Type:

Private

Share

in

Government

____________________

Others: _________________

Monthly

Employment

Business:

Status:

Regular

Business

(%):
Income

_________________________

Probationary
Others: ___________________
Position/Rank __________________________
Monthly Income ________________________

* if less than six (6) months in

current employment, please fill-up
below:
Previous Employer:
_________________________________________
Yrs. In company: __________________
Position/Rank: ____________________

Are you a member of another organization (coop, ngos, etc) yes (specify)_________________
Position: _____________________
Type of Account

BANK ACCOUNT INFORMATION

Bank

Branch

CREDIT CARD INFORMATION

Card Number
Credit Limit

Card Issuer

CHARACTER REFERENCES
Relation
Address

Name

Name

Type of Loan

Monthly Gross
Income

Member Since

Contact Number

TRADE REFERENCES
*if self-employed put at least two (2) trade references
Business
Address

Contact No.

OTHER LOAN DETAILS

Bank or Institution
Monthly
Outstanding
Amortization
Balance

Other
Monthly
Income

INCOME AND EXPENDITURES

Source of
Annual Living
Other
Expenses
Income

Maturity Date

Annual
Taxes

Loan
Payments

I/We hereby certify that all the data and statements in this application are correct and are made for the
purpose of obtaining credit, and the signature(s) appearing thereon is(are) genuine. I/We authorize you to
obtain such information as you may require connecting the statements made in this application and that
the sources which you may apply are authorized to provide any information relative to this application.
I/We agree this will remain your property whether the credit is granted or not.
_____________________________________

____________________________________

Signature of Applicant over printed name

Witnessed By
1.

Membership

Signature of Spouse over printed name

TO BE FILLED-UP BY THE COOP

2. CI/BI (Loan Officer)
3.
General

Committee

_________________________

4. PMES

Manager

Application

Date/s

no.:___________________

conducted:_________________

PMES Result:
Remarks:

Date
Received:____________________

CI/BI

Interviewed

Submitted:__________

by:___________________

Recommendation:

Results

Date
Interviewed:_________________
Date

of

PMES:____________________
PMS Batch No.:___________
Date

of

PMES:

___________________

BOARD OF DIRECTORS

COOP MANAGEMENT
TEAM (COMAT)

CREDIT
COMMITTEE

Signature of Secretary
Date Approved:

Received

Credit Limit:

SKETCH/LANDMARK OF RESIDENCE

Certified by:

__________________________________
(Opisyales o Myembro ng coop na nag recruit o nag imbita sa kalahok ng PMES)
Petsa: _______________________________