PGT CREDIT COOPERATIVE

#299 Brgy. Samput Paniqui, Tarlac

REG. NO. 9520-100300033849
TIN: 622-604-847-000

LOAN APPLICATION FORM

Amount Applied: Loan Term: Date:

Purpose:
Mode of Payment [ ] Cash [ ] Post Dated Check [ ] Salary Deduction [ ] ATM
Repayment Schedule: [ ] Daily [ ] Weekly [ ] Monthly
Property Description: Establish Value:
Collateral Offered:
Property Description:
PERSONAL INFORMATION OF THE BORROWER Membership/Passbook No. ___________
Last Name First Name Middle Name

Nickname: Suffix: Sex [ ] Male

[ ] Jr [ ] Sr [ ] Female
Place of Birth: Date of Birth: Age: 2x2 pic

Civil Status: [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ] w/Live-in

Partner

Permanent Address: Resident: No. of Years:

[ ] Yes [ ] No
City/Provincial Address: Contact Person & No.:
(Province)
Business/Employer: Occupation: Net Income Per Month:

Business/Employer Address:
Home Ownership: [ ] Owned [ ] Mortgaged [ ] Rented [ ] Free Use No of Dependents: Vehicle Owned:
M___F___
INFORMATION ON SPOUSE
Last Name First Name Middle Name

Nickname: Suffix: Sex [ ] Male

[ ] Jr [ ] Sr [ ] Female

Place of Birth: Date of Birth: Age:

Permanent Address: Resident:

[ ] Yes [ ] No
City/Provincial Address: Contact Person & No.:

Business/Employer: Occupation: Net Income Per Month:

Business/Employer Address:

INFORMATION ON CO-MAKER
Last Name First Name Middle Name

Nickname: Suffix: Sex [ ] Male

[ ] Jr [ ] Sr [ ] Female

Place of Birth: Date of Birth: Age:

Civil Status: [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ]Live-in Partner

Present & Permanent Address: Resident: No. of Years:

[ ] Yes [ ] No
Business/Employer: Occupation: Net Income Per Month:

IDENTIFICATION OF BORROWER
ID Type ID Number Issue Date/Expiry Issued By Last Update Date
Date

DATA ON PARENTS
Mother’s Maiden Name: Last Name: First Name: Middle Name:
Father: Last Name: First Name: Middle Name:

SOURCES OF INCOME: [ ] Business [ ] Employment [ ] Pension [ ] OFW Remittance [ ] Direct Selling [ ] Others______________
INCOME
Net Household Income (Borrower and Spouse) Php.
Other Income came from Php.
TOTAL Php.
EXPENSES Php.
Food Php.
Rent Php.
LPG Php.
Laundry and Toiletries Php.
Utilities (Electricity + Water + Cable + Internet + CP Postpaid/Prepaid) Php.
Medicine (Maintenance/Vitamins) Php.
Transportation Php.
Employment Allowance Php.
School Allowance/Tuition Php.
Loan Payments (Total Bank/FI Amortization) Php.
Sub-Total Php.
Miscellaneous (10%) Php.
TOTAL Php.
Net Disposable Income (Income – Expenses) Php.

CONFORME’
I warrant the truth and veracity of all the data, information furnished herein to the best of my knowledge. Any misdeclaration that
will be discovered during credit investigation will automatically cause the disapproval of this loan. I expressly submit to any
credit investigation as well as to furnish any other requirements of the cooperative by reason hereof.

____________________________ ______________________________ ____________________________ _____________

Applicant’s Signature Marital Consent Co-Maker Date

(FOR COOP’S USE ONLY) do not fill-up beyond this line.

Borrowers Dealings with the Cooperative
Original Outstanding Amortization Deposits and Share Outstanding
Type of Loan ADB
Amount Balance Amt. Capital Balance
Savings Deposit:
Time Deposit:
Spec. Savings Dep:
Total Share Capital:
ATM Savings
Total