CLASS D

ERCA-RCEF Lending Program Attach 1x1

APPLICATION FORM
Land Bank of the Philippines (LBP)
Pangasinan Lending Center (PANLC)
photo
of borrower/
signatory
2nd Floor LANDBANK Urdaneta Building, MacArthur
Highway, Nancayasan, Urdaneta City, Pangasinan
Telephone Numbers : (075) 656-2013 / 2019
E-mail Addresses : plcreg1@yahoo.com /
lbppangasinanlc@gmail.com

A. Applicant/Business Profile
Applicant/Business Name Tax Identification Number
- - - 0 0 0

Applicant/Business Address Contact No/s. Contact Person/s

Applicant Type(Pls. Check)

Individual / MSE Cooperative / Famers Org. / Assn. Financial Institution / MFI
Farmer Multi-Purpose Cooperative Rural bank
Fisher Credit Cooperative Thrift Bank
MSE Farmer’s Organization / Association Cooperative Bank
Fisher’s Organization / Association MFI
Others (please specify)
Nature of Business (Pls. refer to list below) Number of years in business

Registered with (Pls. Check) Registration Number Date of Registration

SEC DTI CDA Others (Pls.
Specify)

B. Financial Requirement
Types of Facilities Proposed Tenor /
Amount Purpose (Please Check)
(Please Check) Maturity
Short Term Loan _____ days PN ₱ Working capital
Term Loan years ₱ Acquisition of ______________
Others (Pls. Specify) ₱ Construction of _____________
Others : _________________

C. Project / Commodity Financed (Pls. Check)

Agricultural Production
Crop Production (pls specify)
Palay Production
Fishery (pls specify)
Fixed Asset Working Capital / Trading
(please specify)
Acquisition of (Pls. Specify)
Construction of (Pls. Specify) Others (Pls. Specify)

Others (Pls. Specify) Others (Pls. Specify)

D. Existing Relationship with LBP (Pls. Check)

Loans Time Deposit Trade facilities
Savings account/ATM Trust Account Remittance services
Current account/ATM Treasury Services Others (Pls. Specify)

E. Existing Relationship with Other Banks

Name of Bank Existing Products/Services Availed
 F. Collateral Offered (Pls. Check)
Description Acquisition Cost
NOT APPLICABLE

G. List of Board of Directors and Key Officers

Name of Officer Position
NOT APPLICABLE

H. Do you have any involvement in court case/s?

Have you been, or are you presently, a party on any proceedings tried by a court of law?
No Yes (please specify)

Sworn Statement
I/We affirm that each of the statement made in this application is true and correct and
agree to notify LBP of any material change affecting the information contained herein. I/We authorize
LBP to obtain and verify such information as may be required covering this application from the above
references or any other sources. I agree that all information obtained by LBP shall remain its property
whether or not loan is granted.

I/We hereby swear that I/we have no outstanding loan/s from LBP, or outstanding loans from
any other formal lending institutions / other creditors and DA-Agricultural Credit Policy Council (ACPC)
credit conduits for the same project being applied for.

I/We hereby agree that, should there be any misrepresentation discovered, LBP may cause
the outright disapproval of the loan application and, if the loan has been granted, LBP may
immediately declare the loan due and demandable.

IN WITNESS WHEREOF, I/we have hereto signed in this _________ day of

___________________ 2021 at _______________________________, Pangasinan.

_________________________________
Signature Over Printed Name of Applicant

SUBSCIRBED AND SWORN to before me, this _________ day of ___________________

2021, affiant exhibited to me his/her _____________________________ issued on
______________________________.
Notary Public

Doc No. ;
Page No. ;
Book No. ;
Series of 2021 .