REGION IV-A QUEZON PROVINCE PUBLIC SCHOOL TEACHERS AND EMPLOYEES ASSOCIATION, INC.

(QPSTA)
LUCENA CITY

DAMAYAN MEMBERSHIP APPLICATION FORM

NAME :_____________________________ CIVIL STATUS:_____________________

DATE OF BIRTH:______________________ OCCUPATION:___________________________
HOME ADDRESS:____________________________________________________________________
SCHOOL/OFFICE ADDRESS:_________________________________________
TEL. NO./CEL.NO.______________________________________________________________
NAME OF HUSBAND/WIFE: _____________________________________________________
OCCUPATION:________________________________________________________________

BENEFICIARIES RELATIONSHIP DATE OF BIRTH

DAMAYAN BENEFIT SIMPLE TERMS AND CONDITIONS

1. First payment in the amount of Php200.00 shall be collected upon membership

and the contribution per year from each QPSTA Member shall be taken through
deduction from their annual dividend from the QPSTECC;
2. The qualified beneficiaries of married members are their spouse and legitimate
children while those of single members are their parents. Any valid document
that will support as beneficiary of the deceased shall be recognized and validated
by the association.
3. Upon the death of a member, a contribution of Php20,000.00 from the fund will
be given to the surviving beneficiaries.

I ___________________________, an applicant for the QPSTA DAMAYAN

membership do hereby agree on the above simple terms and conditions. I promise to
uphold the Constitution and By-Laws of the QPSTA and support its program and projects.

__________________________
Signature of Applicant
MEMBERSHIP FEE OF PhP100.00 and/or DAMAYAN FEE of PhP200.00 O.R. NO.____________

APPROVED:

RONALDO V. GARCIA
President