BIR SAVINGS AND LOAN ASSOCIATION INC.

1ST FLOOR DPC BLDG., BIR NAT'L OFFICE COMPOUND, DILIMAN, Q.C.
Office No. 8927-0996, BIR Trunkline 8929-7676 loc. 7519, 7520, 7521
Facebook: fb.com/birsala1969, Website: www.birsala.com
BIRSALA Form No. 1 ( Revised June 2022 )

New Member Re-Membership Update TIN:

MEMBERSHIP FORM
A. Personal Information
NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) DATE OF BIRTH (MMDDYYYY)

GENDER CIVIL STATUS PLACE OF BIRTH (CITY/MUNICIPALITY,PROVINCE)

Male Female Single Married Widowed Separated Others _____________
RELIGION NATIONALITY LBP ACCOUNT/PAYROLL (ATM)

PRESENT ADDRESS (RM./FLR./UNIT NO. & BLDG NAME) (HOUSE/LOT & BLK. NO.) (STREET NAME) (SUBDIVISION)

(BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) (COUNTRY) ZIP CODE

PERMANENT ADDRESS (RM./FLR./UNIT NO. & BLDG NAME) (HOUSE/LOT & BLK. NO.) (STREET NAME) (SUBDIVISION)

(BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE) (COUNTRY) ZIP CODE

MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS TELEPHONE NUMBER

POSITION OFFICE/DIVISION NAME PLACE OF ASSIGNMENT DATE ENTERED BIR

SOURCE OF FUND DO YOU HAVE OTHER SOURCE OF INCOME: YES NO PEP

SALARY IF YES, PLEASE SPECIFY: _________________________________________________
SPOUSE (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) OCCUPATION DATE OF BIRTH (MMDDYYYY)

B. Beneficiaries
(LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX) RELATIONSHIP DATE OF BIRTH (MMDDYYYY)
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C. Certification

I certify that the information provided in this form are true and correct. I also agree to BIRSALA'S Privacy Registrant is required to affix fingerprints.
Notice and give my consent in the processing of my personal data in accordance with the Data Privacy Act of 2012.

PRINTED NAME SIGNATURE DATE RIGHT THUMB

>>> FOR BIRSALA USE ONLY <<<

Official Receipt Number: Date:
Amount in Words: Amount in Figure: (P________________)
Received Payment in the form of Cash Cheque Others
Cashier __________________________