ETTEHADONNISA CONSUMERS COOPERATIVE

POBLACION, DINAS, ZAMBOANGA DEL SUR

Certificate of Registration No. 9520-1090000000048539
Certification of Compliance CIN No. 90202048539
Cell No. 0938-111-7778 / 09166859447 jienasilin11@gmail.com

MEMBERSHIP FORM

Name: _________________________________________________ Gender: _______________________

Address: __________________________________________________________________________________
E-mail Address: _________________________________________ Contact Number: _______________
Facebook Account:_______________________________________ TIN Number: __________________
Place of Birth: __________________________________________ Date of Birth: __________________
Civil Status: ____________________________________________ Citizenship:____________________
Height: ____________________ Weight: ___________________ Religion: ______________________
Spouse: ________________________________________________ Occupation: ___________________
Name of Children: _______________________________________ Date of Birth:__________________
_______________________________________ ___________________
_______________________________________ ___________________
_______________________________________ ___________________
_______________________________________ ___________________
_______________________________________ ___________________
Father’s Name: __________________________________________ Occupation:___________________
Mother’s Name: _________________________________________ Occupation:___________________
Person to be contacted in case of emergency: _____________________________________________________
Address: _______________________________________________ Contact No.: __________________

I ______________________________ surely subscribe the 8 shares from the cooperative but I have to pay the
(Name)
2 shares only for the membership of the coop. I promise to pay the remaining shares within 2 years.

AFIPA M. SALIK
Signature over Printed Name Treasurer

FARIDA U. COK

B.O.D. Chairman