APPLICATION FOR CANDIDACY

1CISP ANNUAL ELECTION 2022

Date Filed : _________________________

Desired Position : __________________________________________

 Regular Member of the Board of Directors

 Independent Director
 Audit and Inventory Committee Member
 Election Committee Member

CANDIDATE’S INFORMATION

Full Name (Surname, First Name(s), Middle Name) Birthdate Age

Permanent Address

Mobile Number Email Address

Highest Educational Attainment Current Occupation

Name of Employer Cooperative/Organization Represented

Address of Cooperative/Organization Represented

Position in the Cooperative being represented CDA Registration No./Date of Registration

Contact Number (Of Cooperative being represented) Email Address of Cooperative Represented

OTHER COOPERATIVE/ORGANIZATION AFFILIATIONS

Name of Cooperative/Organization Position

I hereby certify that the above information are true and correct to the best of my personal knowledge.

________________________________________
Signature over Printed Name

TO BE FILLED UP BY CONCERNED 1CISP PERSONNEL

Share Capital as of December 31, 2021: ____________________________________

Plans Subscribed in 2021

Life Non-Life
Plans Premium Plans Premium
LPPI Fire Insurance
GBLISS Motor Insurance
GYRT MSPR
SIP Surety Bond
PAI/ICARD Home Protect
SII CHMF
KOOPAMILYA Ward/Semi-Private/Private

ELLECTION COMMITTEE
( ) Approved ( ) Disapproved
Remarks ELECOM In-charge Name & Signature

Note: Please attach to this form your complete resume with 2x2 colored formal picture (in business attire) and kindly submit on or before March 21,
2022.