Here

Member No.
AGREEMENT
Account No.
I hereby apply for membership in PSSLAI. If this application is
approved, I agree and pledge to abide by the Articles of Incorporation,
By- Laws, Rules and Regulation and Policies and Procedures of the
Association.
I fully recognize the PSSLAI's authority to reject, deny or terminate my
membership at any given point in time without prior notice to me in
order to safeguard the interest of the General Membership.
I fully understand that in the case of my demise, the laws of the
association will apply in accordance with the Civil Code of the
Philippines.
It is my responsibility to inform PSSLAI with regards to changes and
updates of my personal information.
I hereby waive my right to file for any damage as a result of my nonupdate or non-disclosure of personal information.
I understand that PSSLAI may demand to submit or update any
document it may require as part of its documentation requirement.
I hereby authorize PSSLAI to transfer funds from my Capital
Contribution Account to my Premium Savings Account in the event
that I exceed the maximum dividend ceiling based on the quarterly
placement limit of the Capital Contribution as set by PSSLAI.
I hereby acknowledge that a membership card shall be issued to me
by the Association upon approval of my membership application. The
membership card is a requirement for all the transactions of the
Association and I hereby bind myself liable for all obligations and
liabilities incurred with the use of the PSSLAI Membership Card.
Furthermore, we agree with the TERMS AND CONDITIONS
governing the issuance of the PSSLAI Membership Card.
I declare under the penalties of perjury that all information I made
covering this application has been made in good faith and to the best
of my knowledge and belief, is true and correct.
I hereby designate the following as my beneficiaries to whatever
benefits may accrue to me as member of the Association in the event
of death pursuant to PSSLAI rules and regulations.
I hereby agree with the terms and conditions of this agreement and
accordingly, I am applying for the PSSLAI's Mobile Service System.
1.
( ) CAPCON ( ) PSA ( ) PDA ( ) CASA
( ) STD
Others: _______________
( ) Regular
( ) Associate ( ) Individual Account
( ) New Account
( ) Update
Primary Member's Name: (SURNAME, FIRST NAME, MIDDLE NAME)
Birth Date:
( ) Joint Account
2.
Birth Place:
Civil Status:
3.
Nationality:
Sex:
4.
Present Address: ( ) owned
( ) rented
Permanent Address:
Tel. No.:
5.
Cell No.:
6.
7.
Tel. No.:
Tax Identification, SSS No. or GSIS No./PNP ID:
8.
Nature of work:
Name of Employer:
Nature of Business if Self-Employed:
Rank/ Position:
Name of Co-depositor/Trustor: (SURNAME, FIRST NAME, MIDDLE NAME)
Type of Account:
Source of Funds:
Name of Co-depositor/Trustor: (SURNAME, FIRST NAME, MIDDLE NAME)
( ) &/or Account
( ) AND Account
( ) ITF Account
9.
10.
I/We hereby agree to be governed by your regulations to this account. Please honor the following signature/s in the payment of funds or
the transaction of other business on my / our account subject to the instructions given: ( ) Any one ( ) All
Primary Member Signature
Co-Depositor/Trustor Signature
Co-Depositor/Trustor Signature
1
2
3
1
2
3
1
2
3
11.
Signature over Printed Name of Member/Trustor
Kindly honor the signature of the person above and whose signatures appear thereon as a CO- DEPOSITOR for my account. As a CO-DEPOSITOR, the above named person shall have the right and the authority
to make official transactions concerning said account, including but not limited to the making of deposits, withdrawals or transact loans from the same, unless written and notarized instructions to the contrary is issued by me
or by the said CO-DEPOSITOR or unless otherwise ordered by a court of competent authority.
NAME
BIRTHDATE
RELATIONSHIP
SURVIVORSHIP AGREEMENT
Upon death of any of the co-depositor/s, the whole amount of the funds shall belong to the
surviving co-depositor/s and may forthwith be withdrawn by the latter, within the limits prescribed
by law. I freely execute this agreement this ______ day of _______________, year
_____________.
Signature of Joint Depositor
Signature of Joint Depositor
Signature of Joint Depositor
Signature over Printed Name of Member/ Trustor
AUTHORIZATION FOR DEDUCTION AND REMITTANCE
(DEED OF UNDERTAKING)
To whom it may concern:
FINANCE AUTHORIZATION and AUTOMATIC SALARY DEDUCTION FORM
To whom it may concern:
I, __________________________________________________________________ a member of PNP/__________ (Branch of
Service) and a loan applicant of Public Safety Savings and Loan Association, Inc. (PSSLAI), do hereby
authorize the ________________________________ to deduct from my monthly payroll / monthly pension /
retirement
benefits / commutation
of
leaves
and
pay
the
amount of
(Php_________________________________) ___________________________________________________________________________
until my loan obligation is fully paid. This authorization shall not be rescinded or revoked without the
written approval of PSSLAI. If this authorization is not timely effected on my behalf, I shall pay the unpaid
amount and/or penalties thereof.
This will likewise serve as an authorization for the ____________________ to release in favour of PSSLAI
whatever amount due to them in case of separation, dismissal, resignation, termination and other causes
not herein mentioned whatsoever. I am allowing the PNP/__________ (Branch of Service) to deduct more
than the allowed percentage of benefits that can be remitted as payment for any liabilities incurred by me.
We concur that PSSLAI shall be given first priority in any benefit we will receive against any loan obligation
from other institution. This authority shall be in full force until my loan is fully paid. It does not relieve me of
my obligation to ensure that the deductions are made from my salary/ pension/other benefits and remitted
to PSSLAI.
I, _______________________________ a member of the PNP/__________ (Branch of Service) presently assigned at
_____________________________, do hereby execute this authorization to undertake the following:

Authorize the PNP/__________ (Branch of Service) Finance Service to deduct from my payroll the
amount of Php1,100.00 beginning _______________, 20_____ as my Capital Contribution to be credited
to my account representing initial deposit and payment for Membership and ID fee.

Authorize the
Finance
Service
to
deduct
from
my
payroll
account
the
amount
of
Php __________________ every month beginning _____________, 20_______ as my monthly Contribution /
deposit in my
CAPCON

Stop my
CAPCON

Adjust my monthly
PSA
PSA
CASA with Account number ___________________________.
CASA with Account number ___________________________.
CAPCON
PSA
CASA with Account number _____________________.
From Php ______________________ to Php _________________________.
In addition, I/We hereby authorize the PNP/__________ (Branch of Service) Finance Service to collect/ deduct
from our salaries and/or benefits in accordance with the terms and conditions of the Promissory Note
Pursuant to Republic Act 8792 otherwise known as the E-Commerce Act of 2000 in relation to Republic Act
8367 otherwise known as the Revised Non-Stock Savings and Loan Association Act of 1007, by availing of
loan from PSSLAI through its electronic data facilities, that by virtue of the nature of this transaction, one
being constituted upon electronic means and/or computer generated, I fully understand that NO PHYSICAL
SIGNATURE may be required of me but my agreement of the terms and conditions governing the loan is
sufficiently manifested by the fact of my use of the electronic/computerized loan facility provided by
PSSLAI. A digital/ electronic signature may be provided evidencing my full agreement and consent to this
transaction.
which may go down to an amount of: ___________________________________________________________________until
the loan plus interest, fines, costs and other expenses are fully paid.
This will likewise serve as an authorization for the PNP/__________ (Branch of Service) Finance Service to
release in favour of PSSLAI whatever amount due PSSLAI in case of separation, dismissal, resignation,
termination from service for whatever cause, or underpayments resulting from my own fault/negligence.
PSSLAI will receive whatever benefits are due us from the PNP/__________ (Branch of Service) equivalent to
the total amount we owe PSSLAI. We concur that PSSLAI shall be given first priority in any benefit we will
receive from the PNP/__________ (Branch of Service).
BORROWER’S SIGNATURE OVER PRINTED NAME
As Co-maker, it is understood that in case of default by the borrower as a result of separation or dismissal, I
ACKNOWLEDGEMENT
BEFORE ME, a Notary Public for _________________, this ______day of __________, 20_______, personally
appeared who exhibited to me his/her competent evidence of identification (CEI) the details of which are
provided next to their names as follows:
NAME ___________________________________________________ CEI PRESENTED ______________________________________
ISSUED AT __________________________________ ON ______________________________________ VALID UNTIL
____________________________________
Known to me to be the same persons who executed the foregoing instrument and acknowledged to me
that the same is his free and voluntary act and deed.
WITNESS MY HAND AND SEAL at the place and on the date first mentioned.
Doc. No. ___________
Page No. ___________
Book No. ___________
Series of 2014.
am authorizing PNP/__________ (Branch of Service) Finance to release and/or deduct in favour of PSSLAI
AUTHORIZATION FOR DEDUCTION AND REMITTANCE
(DEED OF UNDERTAKING)
FINANCE AUTHORIZATION and AUTOMATIC SALARY DEDUCTION FORM
To whom it may concern:
whatever amount is due to PSSLAI from whatever benefits due me.
MAKER’s SIGNATURE OVER PRINTED NAME
CO-MAKER’s SIGNATURE OVER PRINTED NAME
CO-MAKER’s SIGNATURE OVER PRINTED NAME
To whom it may concern:
I, __________________________________________________________________ a member of PNP/__________ (Branch of
Service) and a loan applicant of Public Safety Savings and Loan Association, Inc. (PSSLAI), do hereby
authorize the ________________________________ to deduct from my monthly payroll / monthly pension /
retirement
benefits / commutation
of
leaves
and
pay
the
amount of
(Php_________________________________) ___________________________________________________________________________
until my loan obligation is fully paid. This authorization shall not be rescinded or revoked without the
written approval of PSSLAI. If this authorization is not timely effected on my behalf, I shall pay the unpaid
amount and/or penalties thereof.
This will likewise serve as an authorization for the ____________________ to release in favour of PSSLAI
whatever amount due to them in case of separation, dismissal, resignation, termination and other causes
not herein mentioned whatsoever. I am allowing the PNP/__________ (Branch of Service) to deduct more
than the allowed percentage of benefits that can be remitted as payment for any liabilities incurred by me.
We concur that PSSLAI shall be given first priority in any benefit we will receive against any loan obligation
from other institution. This authority shall be in full force until my loan is fully paid. It does not relieve me of
my obligation to ensure that the deductions are made from my salary/ pension/other benefits and remitted
to PSSLAI.
I, _______________________________ a member of the PNP/__________ (Branch of Service) presently assigned at
_____________________________, do hereby execute this authorization to undertake the following:

Authorize the PNP/__________ (Branch of Service) Finance Service to deduct from my payroll the
amount of Php1,100.00 beginning _______________, 20_____ as my Capital Contribution to be credited
to my account representing initial deposit and payment for Membership and ID fee.

Authorize the
Finance
Service
to
deduct
from
my
payroll
account
the
amount
of
Php __________________ every month beginning _____________, 20_______ as my monthly Contribution /
deposit in my
CAPCON

Stop my
CAPCON

Adjust my monthly
PSA
PSA
CAPCON
CASA with Account number ___________________________.
CASA with Account number ___________________________.
PSA
CASA with Account number _____________________.
From Php ______________________ to Php _________________________.
In addition, I/We hereby authorize the PNP/__________ (Branch of Service) Finance Service to collect/ deduct
from our salaries and/or benefits in accordance with the terms and conditions of the Promissory Note
Pursuant to Republic Act 8792 otherwise known as the E-Commerce Act of 2000 in relation to Republic Act
8367 otherwise known as the Revised Non-Stock Savings and Loan Association Act of 1007, by availing of
loan from PSSLAI through its electronic data facilities, that by virtue of the nature of this transaction, one
being constituted upon electronic means and/or computer generated, I fully understand that NO PHYSICAL
SIGNATURE may be required of me but my agreement of the terms and conditions governing the loan is
sufficiently manifested by the fact of my use of the electronic/computerized loan facility provided by
PSSLAI. A digital/ electronic signature may be provided evidencing my full agreement and consent to this
transaction.
which may go down to an amount of: ___________________________________________________________________until
the loan plus interest, fines, costs and other expenses are fully paid.
This will likewise serve as an authorization for the PNP/__________ (Branch of Service) Finance Service to
release in favour of PSSLAI whatever amount due PSSLAI in case of separation, dismissal, resignation,
termination from service for whatever cause, or underpayments resulting from my own fault/negligence.
PSSLAI will receive whatever benefits are due us from the PNP/__________ (Branch of Service) equivalent to
the total amount we owe PSSLAI. We concur that PSSLAI shall be given first priority in any benefit we will
receive from the PNP/__________ (Branch of Service).
BORROWER’S SIGNATURE OVER PRINTED NAME
As Co-maker, it is understood that in case of default by the borrower as a result of separation or dismissal, I
ACKNOWLEDGEMENT
BEFORE ME, a Notary Public for _________________, this ______day of __________, 20_______, personally
appeared who exhibited to me his/her competent evidence of identification (CEI) the details of which are
provided next to their names as follows:
NAME ___________________________________________________ CEI PRESENTED ______________________________________
ISSUED AT __________________________________ ON ______________________________________ VALID UNTIL
____________________________________
Known to me to be the same persons who executed the foregoing instrument and acknowledged to me
that the same is his free and voluntary act and deed.
WITNESS MY HAND AND SEAL at the place and on the date first mentioned.
Doc. No. ___________
Page No. ___________
Book No. ___________
Series of 2014.
am authorizing PNP/__________ (Branch of Service) Finance to release and/or deduct in favour of PSSLAI
whatever amount is due to PSSLAI from whatever benefits due me.
MAKER’s SIGNATURE OVER PRINTED NAME
CO-MAKER’s SIGNATURE OVER PRINTED NAME
CO-MAKER’s SIGNATURE OVER PRINTED NAME