CEAP Retirement Fund, Inc.

# 7 Road 16, Bagong Pag-asa, 1105 Quezon City

Landlines: (02) 7987-0348; (02) 8875-9285 | Mobile Nos.: (0917)7054379; (0918)9598275
E-mail Address: retirement.membership@ceap.org.ph

APPLICATION and UNDERTAKING TO SIGN the RELEASE Form

I/We, on my/our behalf and/or for and on behalf of the BENEFICIARIES we represent, hereby apply to receive the
retirement/separation benefit due me/us in the amount of: THIRTY NINE THOUSAND ONE HUNDRED SIXTEEN PESOS & 58/100
(Php39,116.58) from the CEAP Retirement Fund, Inc. and the Trustee of
the Fund for the benefits under the CEAP Retirement Plan arising from or on account of:

Voluntary Separation/Resignation

Termination (Refund of Voluntary Contribution)

Redundancy / Retrenchment / Involuntary Due to Medical

X Retirement (Early/Optional/Normal/Late)

Disability

Death

Upon the credit of the aforementioned amount to my/our bank account, I/We hereby undertake to immediately sign and
deliver to the CEAP Retirement Fund, Inc. the ACKNOWLEDGMENT and RELEASE Form attached hereto, without further delay on
my/our part.

I/We hereby manifest that I/we shall comply with the terms of this Application and Undertaking.

IN WITNESS WHEREOF, I/we have set my/our hand and signature this ______ day of _________________ 20_____
at ____________________, Philippines.

Signature

Printed Name
Approved By School/Company Authorized Signatory:

Signature Date

Printed Name School/Company Name

Original – Trustee
1 copy - School