APPLICATION FOR ASSOCIATE MEMBERSHIP I hereby apply for membership in the EXCELLENT PEOPLE’S MULTI-PURPOSE COOPERATIVE (EPMPC), and agree to faithfully obey its rules and regulations as set down in its bylaws and amendments thereof, or elsewhere, and the decisions of the general membership as well as those of the board of directors. I have paid the required membership fee of TWO HUNDRED PESOS (P200.00). I also, hereby pledge to continuously subscribe for as long as I am a member shares with par value of TWO HUNDRED PESOS (P200.00) of the Share Capital of said cooperative. I promise to pay my subscription in semi-monthly installments of P _______________. ________________________ Signature of Applicant PERSONAL DATA Name _________________________________________________________________________________ Civil Status ____________ Date of Birth __________________ Place _____________________________ Present Address ________________________________________________________________________ ________________________________________________________________________ Nearest Relative/Beneficiary ______________________________________________________________ Number of Dependents ___________________________________________________________________ Present Position_________________________________ Store ___________________________________ SSS No. _______________________________________ TIN ___________________________________ List of Dependents NAME AGE RELATIONSHIP AUTHORITY FOR MEMBER-EMPLOYMENT PAYROLL DEDUCTION SIR / MADAME: I hereby authorize EPMPC to deduct from my semi-monthly salary/wage based on the cooperative installment plan schedule the following: a. b. c. d. e. Membership Fee Cooperative Share Capital Subscription Company ID Contract Notarial Fee Uniform f. Over Pay g. Hepa/Flu Vaccine and other related h. Optional Installment Credit Card (after 6 mos. of continued service) i. Future Loans and Cash Advances j. HMO Subsidy (after 1 year of continued service) In case I resign or my membership from the Cooperative be revoked, I also give my full authorization to EPMPC to deduct from my last pay any amount I owe from the Cooperative. Very truly yours, _______________________________ Signature of Applicant This application was approved / disapproved by the Board of Directors in its meeting held on ______________________________, 2010 __________________________ Secretary Membership No. ____________ Noted by: ______________________________ Chairperson Date __________________________ “Revised as of 10202010 DPR”