MEMBER UPDATE/REQUEST FORM. Date AccomplishedY __/ Branch/Office ¥ Member Number ¥ v Member Name T Reguer [1] Associate Snead TYPE OF CHANGE (Check the applicable bax, Alterations must be countersianed the member: CO name, OD Address. 1 cathone Number OF tandine TD Email Adress OO cwistaus 1 Nature of Work 1 Nature of Business 1 Name otemployer sources of Funds Ow Oss O css 1 Membershi Type from Associate Member to Regular Member O otters 1 specimen Signature Pease sig within the tivee (3) boxes, No need to sign If there ne change i signature) D1 No change in member's personal information chock (/) the applicable request Box Ay altrato TL ssvance of Bank Certification / Bank Statement FEES / CHARGES os Purpose Addressee Bank Certiicaton Request for: Preave release the Bank Cerificate to my authorized LD) Almyfour Accounts representative whose slnatue appears blow 1 ony this/these Account Number(s) Signature over printed name of Representative Replacement of Lost Passbook Occ Glrsa O) casa] ommers. Replacement of Lost ID TD Reneval/Damaged ID Reactivation / Update / Change of Mobile Number in the iTrack Facility to. By reactvating/updatina/changing my moble number enrolled n the Track feciity, hereby agree and consent tobe bound bythe same declaration and undertaking | signed when Iregistered forthe Track, and pledge to abide by the polcles, rules, regulation of PSSLA pertaining tothe Track “Affidavit of Loss (Form available) Notary ‘Others ooo) oO ooo TOTAL Fees & Charges | hereby certiy that | voluntarily disclosed the aloove information pertaining to my person and hereby authorize PSSLAY, its officers, employees or representatives to collect/ provide information fromy to my Branch of Service or Employers and use the same information, personal or sensitive as dined uncler RA 10173, in connection with my membership, loan application/loan availment, capital contribution and deposit placements, loan collections, loyalty rewards program, and for all other legit mate purposes relative to the foregoing. | confirm that | had authorized my Branch of Service or Employers to provide all necessary information to PSSLAI relative to the above mentioned, Also, consent to the disclosure/ sharing of my information to accredited/affllated third parties solely for the aforestated purposes. | hereby confirm that by providing personal data, | agree to be bound by the PSSLAI Privacy Terms and Conditions and Notice found in www psslaicom, | urther authorize PSSLAI to update my registered mobile number in Track using my updated cell phone number as indicated above, and | agree to be bound by the same terms and conditions set forth in the Sworn Declarations and Undertaking Relating to Enrollment in the PSSLAI iTrack | have previously signed, Finally, authorize PSSLAI to process any instruction hereby written, Mode of Payment for any feo/s or charge/s connected to my request shall be in the form of [] Cash [-] Debit from Account No. v ‘Signature ove printed nar of Membor Pe ae ee eee Feonfrmedy Date Piemeusgereeee’ eee ese eine