 Private School (PUC)

BEYOND DEPED SALARY LOAN  State Universities & Colleges (SUC)  New
 Reloan
 Government Offices (LGU, etc)
APPLICATION FORM  Private Companies (AEL)
 Multiple

Instructions: PLEASE PRINT ALL INFORMATION LEGIBLY IN CAPITAL LETTERS. Indicate N/A in the fields which are not applicable.
I hereby apply for a loan in the amount of PESOS: _______________________________________________________________________________________ (P_________________________)
for the following purpose:
 Training/Education  Home Renovation  Loan Buy-out
 Medical  Household Consumption/Needs  Others (please state) ________________________
for a term of: _________________________ months, which I promise to pay in accordance with the rules, regulations, terms and conditions of CITY SAVINGS BANK as stipulated in this application
form, the Promissory Note of even date, and such other documents executed together with this loan; all of which I certify to have read and understood clearly.

PERSONAL INFORMATION
Client Name (Last Name, Given and Middle Name)  Single  Married
Civil Status
 Widowed Separated

Date of Birth (mm/dd/yyyy) Birth Place Sex  Male  Female

Nationality Religion Mobile No.

TIN GSIS/SSS No. Email Address

Present Address (No./Street/Village/Barangay/District/Municipality/City/Town/Province) Zip Code

 Owned  Living with Parents  Company Quarters  Mortgaged Length of Stay ______ Years ______ Months
Ownership
 Living with Relatives  Rented  Others (specify): ________________________ Res. Tel. No.

Permanent Address (No./Street/Village/Barangay/District/Municipality/City/Town/Province) Zip Code

 Owned  Living with Parents  Company Quarters  Mortgaged Length of Stay ______ Years ______ Months
Ownership
 Living with Relatives  Rented  Others (specify): ______________________ Res. Tel. No.

SOURCE OF FUNDS
Employer Office Tel. No. & Local

Address Office Email Address

Position Basic Monthly Salary PHP

Department Monthly Recurring Allowance PHP

Nature of Work Employee No. Date Hired

SPOUSE INFORMATION (IF APPLICABLE)

Spouse’s Name (Last Name, Given and Middle Name) Date of Birth

Birth Place

Employer/Business Mobile No.

Position Email Address

Monthly
Nature of Work/ Business USD/PHP
Income

DATA PRIVACY AND PERSONAL DATA GATHERING CONSENT

The loan applicant (“Borrower”) acknowledges and agrees that, in the course of his/her loan application with rendering services to CitySavings in the administration or promotion of its lending business;
City Savings Bank, Inc. (“CitySavings”), and throughout the term of his/her loan if such loan application is (d) to any person to whom CitySavings proposes to assign or transfer of its rights and/or duties to the
granted, CitySavings may receive or have access to Personal Information and/or Sensitive Personal loan;
Information and/or any financial information of the Borrower which CitySavings may consider as relevant in (e) to any guarantor or person providing security in relation to Borrower’s obligation;
evaluating the loan application (hereinafter collectively referred to as “Private Information.”) Borrower (f) as required or permitted by law, regulation, court or any regulatory authority; or
expressly consents to the processing, collection, transmission, storage, disposal, use and disclosure of Private (g) as otherwise considered necessary or appropriate by CitySavings.
Information by CitySavings for the following purposes: “Personal Information” as used herein means information provided to CitySavings by or at the direction of
(a) to manage Borrower’s account(s), including endorsement to outsourced collections service Borrower, or to which access was provided to CitySavings by or at the direction of Borrower wherein: (i) the identity
provider in case of default, any consultant, adviser, auditor, counsel, agent, contractor or sub- of an individual is apparent or can be reasonably and directly ascertained; or (ii) when put together with other
contractor of CitySavings performing services for the purpose of assisting or rendering information, would directly identify an individual.
services to CitySavings in the administration or promotion of its lending business; “Sensitive Personal Information” as used herein means any Personal Information that: (i) pertains to an individual’s
(b) to confirm, update and enhance CitySavings’ records; race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations; (ii) pertains to an
(c) for statistical analysis, internally by CitySavings and/or any service provider it may engage for individual’s health, education, genetic or sexual life, or to any proceedings in court; (iii) is issued by government
the purpose; agencies peculiar to an individual, e.g., social security numbers and health records; or (iv) is specifically established
(d) to establish any identity or otherwise as required under applicable legislation; by an executive order or an act of Congress to be kept classified.
(e) to assess Borrower’s credit status on an on-going basis;
(f) for marketing and promotional of CitySavings products; or Furthermore by signing this form, the Borrower understands and expressly waives his/her right under
(g) any other purpose, as considered necessary or appropriate by CitySavings confidentiality laws including but not limited to RA10173 or Data Privacy Act of 2012, RA 1405 or The Law on
Secrecy of Bank Deposits, RA 6426 or The Foreign Currency Deposit Act and RA 8791 or the General Banking Law
In each case, the processing of Private Information may continue after the termination of the loan and their respective implementing rules and regulations and allow processing, storing, access to or sharing of any
agreement. CitySavings may disclose the Borrower’s Private Information: information regarding the aforementioned Salary Loan as well as the Bank products, services and channels which
(a) to a credit reference agency where it may be accessed by other financial institutions to assist the Depositor has activated, enrolled in or availed pursuant to this Form.
assessment of any application for credit made to CitySavings and for debt tracing and fraud
prevention; CONFORME: ____________________________________________
(b) to its parent company or any of its affiliate or subsidiary; Signature over Printed Name of the BORROWER
(c) to any consultant, adviser, auditor, counsel, agent, contractor or sub-contractor of CitySavings
performing services for the purpose of assisting or

——————————DO NOT WRITE BELOW THIS SPACE-FOR CITYSAVINGS USE ONLY——————————

NET PAY VALIDATION CIF No: ____ REDEMPTION
1. MM/DD/YYYY:_________________(Php)_____________ LOAN INFO PLI Name: ________________________________________
2. MM/DD/YYYY:_________________(Php)_____________ Branch Name : ____ PLI Name: ________________________________________
3. MM/DD/YYYY:_________________(Php)_____________ Branch SOL ID : ____ PLI Name: ________________________________________
4. MM/DD/YYYY:_________________(Php)_____________ Scheme Code : ____ SERVICING
Group Code : ____ Branch Name:__________________Scheme Code________

Application received and verified by: ________________________________________________________ Date: ____________________________

Remarks/Exceptions: _________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________
Approved by: ___________________________________________________________________________ Date: ____________________________
Remarks/Exceptions: _________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________
 REFERRER’S STATEMENT (APPLICABLE TO LGU LOANS)
To the Government Unit,
I/We, the referrer/s of ______________________________ (name of borrower), hereby voluntarily and willingly bind ourselves to cooperate with City Savings Bank (the “Bank”) and truthfully
provide accurate and reliable information about the borrower’s address, contact details, and other information requested by the Bank in case the borrower fails to pay his/her obligations for
any reason whatsoever, including the non-implementation or stoppage of his/her salary deductions.
(1)
Name in Print: ________________________________________ Employee No./ID No.: _________________________ Age:_______________________________
Res. Address: _________________________________________ Tel. No.: _____________________________________ Mobile No.: _________________________
Designation: __________________________________________ Date of Birth: _________________________________ Nature of Appointment: _______________
(2)
Name in Print: ________________________________________ Employee No./ID No.: _________________________ Age:_______________________________
Res. Address: _________________________________________ Tel. No.: _____________________________________ Mobile No.: _________________________
Designation: __________________________________________ Date of Birth: _________________________________ Nature of Appointment: _______________

We certify that the information we provided above and the borrower is true and correct.
____________________________________________________ ________ ______________________________________________
Signature over Printed Name of the REFERRER (1) Signature over Printed Name of the REFERRER (2)

NON-AVAILMENT OF OPTIONAL RETIREMENT (APPLICABLE TO LGU LOANS)

 I will not avail of the optional retirement before the ending term of the loan.
Note: If the client refuses to affirm the non-availment of optional retirement or suddenly avails the optional retirement before the ending term of the loan, issuance of post-dated checks
must be required.

LOAN RELEASE AND REFUND INSTRUCTIONS

If my application is approved, I hereby authorize CITYSAVINGS to release the loan proceeds and/or any refund for loan overpayment via:
 Credit to my account with:  City Savings Bank  Union Bank of the Philippines Account number:
 Other designated account: ________________________________________________

Signature of Borrower: _____________________________________________________________ Date: ______________________

CERTIFICATION (TO BE ACCOMPLISHED BY AN AUTHORIZED REPRESENTATIVE OF THE ACCREDITED INSTITUTION)

I hereby certify that:
 The loan applicant is a permanent and regular employee of the company.  The employee is not due for separation from the company in the next twelve months
 The information provided by the employee on date of hiring and salary are true and  Any exceptions/comments:
correct. _____________________________________________________________________________
 The employee is in good standing and has no pending cases against him/her for the past _____________________________________________________________
twelve months.

Signature over printed name of the authorized representative: _________________________________________________ Date: ______________________
Position/Department: ___________________________________________________________________________________

For complaints, you may do either of the following: approach the Consumer Protection and Assistance Officer of the day in the branch where you did the transaction, send a message to 0917-
8746753, or email [email protected]. Rest assured that we will address your concern at the soonest possible time.