MINDORO OCCIDENTAL MEDICAL MISSION GROUP

HEALTH SERVICE COOPERATIVE

Diego Silang St., San Jose, Occidental Mindoro

APPLICATION FORM FOR COOP MEMBERSHIP

(Please fill up this form completely and write legibly)

I, __________________________________, Filipino, of legal age, hereby depose and say: THAT below are
my PERSONAL DATA:

Name (last, first, middle/maiden) : ____________________________________________________________

Birthdate: ________________________________ Birthplace: __________________________________________
Residence and Tel. #: ___________________________________________________________________________
Office and Tel. #: ______________________________________________________________________________
Mailing Address: ______________________________________________________________________________
E-mail Address: ____________________________ Cellular #: ___________________________________________
Profession: ___________________________________________________________________________________
Specialty: _________________________________ Subspecialty: ________________________________________
Present Job/Position: ___________________________________________________________________________
Any Cooperative Affiliation: _____________________________________________________________________
Spouse: _____________________________________________________________________________________

Name of Children/Dependent Birthdates

____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________

EDUCATIONAL BACKGROUND
College (school/course/year graduated): ___________________________________________________________
____________________________________________________________________________________________
Vocational (school/course/year graduated): ________________________________________________________
_____________________________________________________________________________________________
Postgraduate/MD degree/year: ___________________________________________________________________
______________________________________________________________________________________________

ADDITIONAL INFORMATION FOR PHYSICIANS:

Internship : ____________________________________________ Year : ___________________________

Residency : ____________________________________________ Year : ___________________________
Fellowship : ___________________________________________ Year : ___________________________

Hospital Affiliations : __________________________________________________________________________

Membership in Medical Societies: ________________________________________________________________

PMA No. : ___________________________________

PHIC No.: __________________________________
PRC ID No.: ________________________________
 MINDORO OCCIDENTAL MEDICAL MISSION GROUP
HEALTH SERVICE COOPERATIVE
Diego Silang St., San Jose, Occidental Mindoro

THAT I pledge to pay the remaining 75% of my subscribed capital either by:

( ) ___ postdated checks (maximum of 6 months)

( ) Automatic salary deduction for 6 month salary
( ) Automatic deduction from Professional Fee for ___ (max of 6) months
( ) To be paid by my cooperative or corporate account
( ) Extended payments beyond 6 months; 2% monthly interest to be added after the
6th month to remaining amount due, paid in full with postdated checks
( ) I have already paid my subscribed capital in full amount
( ) Others: _________________________________________

THAT
( ) I have no health-related business that will constitute conflict of interest with MMG
( ) My health-related business/investments are as follows; (state content of owner-
ship investment)
___________________________________________________________________
___________________________________________________________________

THAT
My personal interests include; _______________________________________________
__________________________________________________________________________

THAT
( ) I could be tapped to work on the following committees: (check all that applies)
{ } Credit { } Election
{ } Audit/Inventory { } Membership
{ } Any Committee
( ) I don’t wish to work under any committee

And THAT my duties and responsibilities as a member are to:

a. Pay the installment of my share capital subscription as it falls due; to participate in the
capital build-up and savings mobilization activities of the Cooperative;
b. Patronize the Cooperative’s business and services;
c. Participate in the membership education programs;
d. Attend and participate in the deliberation of all matters taken during general assembly
meetings:
e. Observe and obey all lawful orders, decisions, rules & regulations adopted by the
Board of Directors and the General Assembly:
f. Promote the goals and objectives of the cooperative, the success of its business, the
welfare of the members and the cooperative movement in general

Signature of Applicant : ________________________________________

 MINDORO OCCIDENTAL MEDICAL MISSION GROUP
HEALTH SERVICE COOPERATIVE
Diego Silang St., San Jose, Occidental Mindoro

Date Signed : ________________________________________

Community Tax Certificate No. : ________________________________________

Date Issued : ________________________________________

Place of Issue : ________________________________________

TIN : ________________________________________

------------------------------------------------------------------------------------------------------------------------------------------------

For Applicant’s to Associate Membership:

Name of Member-Endorser : _________________________________________

Signature of member-Endorser : _________________________________________

Relationship to Member-Endorser : ____________________________________________

---------------------------------------------------------------------------------------------------------------------------------------------------------------

DO NOT WRITE BELOW [ For use of Membership Committee Members only]

[ ] Approved as: [ ] Regular Member

[ ] Preferred shareholder (Associate)

[ ] Disapproved (state reasons for disapproval): _____________________________________________

____________________________________________________________________________________

[ ] Pending (state reasons): _______________________________________________________________

____________________________________________________________________________________

Received by: ____________________________________________ Date: ____________________________________

Approved by: ___________________________________________ Date: ____________________________________

Signed:

_____________________________________________ _______________________________________

_____________________________________________ _______________________________________
 MINDORO OCCIDENTAL MEDICAL MISSION GROUP
HEALTH SERVICE COOPERATIVE
Diego Silang St., San Jose, Occidental Mindoro

ANNEX I

I am subscribing _____ shares which are equivalent to Php ________ (Php 100/share), of which I a
m paying 25% of my subscribed capital. My schedule of payment for my subscribed capital would be as follow:
1st payment: _________________ Php__________________
2nd payment: _________________ Php__________________
3rd payment: __________________ Php__________________
4th payment: __________________ Php __________________
5th payment: __________________ Php__________________
6th payment: _________________ Php__________________

Requirements:
1) Birth Certificate of dependents and/or
2) Marriage Certificate and,
3) Proof of Billing OR
4) Any Identification Proof with your address AND
5) 1x1 picture
6) Long folder

FOR PHYSICIANS(in addition to above requirements):

1) Diploma from Medical School
2) Certificate of Residency Training
3) Certificate of Fellowship or Diplomate (if any)
4) Photocopy of PRC Id
5) Long Folder