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SALARY LOAN APPLICATION

l"Vaf fey Ban k $@'"
@lla- Date: 64laglat
IMPORTANT: PLEASE FILL-UP THIS FORM C0MPLETELY WRITE N/A lF NOT APPLICABLE PLEASE PRINT.

Last Name First Name Middle Name Date of Birth Nationality Civil Status

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Present Home Address
lr/ Owned Length of Stay Permanlnt Hdme nddress I

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Renred

Livinq with
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Relatives

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Mother's Maiden Name I Cellphone No, TIN Employee lD

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Applied I Loan Purpose Term

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Amount ot Loan

F l4r' bucrn"l Uouot iliild^',, - Av;an t

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Borrower's Gross Salary F ,Ul /L?l- W Food Allowance F .a.6in)
Add: Monthly Allowance P J.Ado Rent

fgTAL P *to,4Jl.6l Transportation / Gasoline F lrdUu

LESS: Power / Water / Telephone P l,gN
Total Loan Deductions F rq.?,r;lo.4u School / Tuition Fee F
Bonowels Net SalarY F lo, €il.-ry Miscellaneous F D,8u-
ADD: OTHER M0NTHLY INCOME

Spouse's Net SalarY P

Net Income from Business / Farm P 5' cn')
P
TOTAL MONTHLY IiICOME F l[, .5H'.5Zf TOTAL MONTHLY EXP€NSES II,d
Name Date oi Birth Cellphone No.

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Years with the Agency
Position
Employeis Name and Address . n
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NameorAsenLLG'#UY" 'TU^J'l l$L fpl4r" I
NameofDisbursingoffice/Treasurer/Principal
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lYearswtththeAgency

For LGU 0nly - Elected For Teacher's 0nly: EmPloyee No

Jellphone No. Current Position

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Name ol Children Date of Birtft School I Employer and Address erade / Posit on

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Name ol Creditors Addross Type of Loan Amoont Granted Date Grafltod 0/S Balance oate Due

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Reterclse Person Relationship Address Cellphone No.

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REAL ESTATE PROPERTY VEHICLES OWNED

Location Typs ot Srowrty Mar*et Valuo Model / Year ::.{@*,Mus

tl/rNDE\{4 P. Arvur< Net Pay after 1VB Loan Amortization

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Name and SignXure ol APPlicant
 UNDERTAKING '
I

lAl1/e hereby certify that all data in this application are correct and complete, and are made for the purpose of obtaining credit, and that the '

signatures appearing hereon are genuine.

lAffe expressly agree that any misrepresentation or material omission by me in this application shall be valid ground for 1st Valley Bank, Inc.,
A Development Bank (1st Valley Bank), at its option, to treat this loan, if approved, as immediately due and payable. I

lAA/eexpressly agree to lstValley Bank's credit policies and procedure in accordance with BSP Circular 855 (Sound Credit Risk Management
Practices), as well as other applicable and related laws/regulations. lAl/e also hereby authorize 1st Valley Bank, its subsidiaries and affiliates,
and third parties selected by 1st Valley Bank to offer its products and services to me/us through maille-maillta/SMs or other means of
communication.
lAffe authorize 1st Valley Bank and its atfiliates/authorized agents to verify and investigate the information contained herein or any documenV
paper submitted in connection herewith, as well as updates or corrections thereof, from whatever sources, if it may deem appropriate. lM/e
hereby waive confidentiality of client information including without limitation, the provisions of R.A. Nos.9510 (Credit Information System Act),
1405 (Secrecy of Bank Deposit Act), 10173 (Data Privacy Aclot 2012), and Sec. 55.1b of R.A. No. 8791 (General Banking Law).
lAVe consent and/or was authorized to give consent to the collection, retention, processing, disclosure of any personal, sensitive personal
and privileged information relating to me, the Partnership/Corporation/Juridical Entity and its officers, directors and stockholders, whether
provided by me or coming to 1st Valley Bank's possession, and sharing of the said personal, sensitive personal and privileged information
to 1st Valley Bank and its offices, branches, subsidiaries and affiliates, accredited third parties/vendors, or other persons or entities that we
may reasonably select, personal information processors, credit reporting or credit reference agencies, credit protection provider, guarantee
institutions, government agencies and private regulatory organizations and other financial institutions, and other outsourced service providers
engaged by 1st Valley Bank as allowed by law and internal Bank policies, for purposes reasonably required by 1st Valley Bank such as, but not
limited to, its conduct of everyday business, performance of daily technological and operational functions, communications technology services
including updates and automation of the systems of 1st Valley Bank and its affiliates, compliance with the law and regulatory organizations,
research and statistics including conduct of surveys, marketing and cross-selling of products and services of 1st Valley Bank, its subsidiaries
and affiliates, sales lead generation, running credit and negative information checks, statistical and risk analysis, data analytics, client profiling
and all other purposes as allowed in the banking industry practice, businesses of lstValley Bank's subsidiaries and affiliates, and by law. I
shall notify 1st Valley Bank in writing, which must be acknowledged by 1st Valley Bank, if l/we do not consent to the processing and disclosure
of the said information with 1st Valley Bank's representative offices, subsidiaries, affiliates, agents, and accredited third parties/vendors or
other persons or entities that lstValley Bank may reasonably select. IAA/e further acknowledge my rightto information, access, correction,
rectification, erasure of my personal, sensitive personal and privileged information, data portability, objection to processing, file complaint and
damages under Data Privacy Act. lAA/e agree that 1st Valley Bank may retain my personal and account information for as long as necessary
for the fulfillment of the purpose for which it was collected and such other purposes that l/we may have consented to from time to time, as
required by pertinent laws and regulations, and provide information when required to do so in accordance with RA 1405, RA 8791 , RA 951 0,
RA 9160, RA 101 73, as amended, and other similar and applicable laws, by court order, and jurisprudence. I agree that 1st Valley Bank shall
not be liable for any loss or damage arising from 1st Valley Bank's disclosure of personal and account information for the above purposes.
lAl/e agree to indemnify and hereby hold 'l st Valley Bank, its directors, stockholders, officers, employees, representatives, agents or other units
of the Bank, including its subsidiaries and affiliates, free and and bgainst any and all liabilities, actions, damages, proceedings,
losses and/or any and all claims of whatever nature that may indirectlyJpom the execution of this consent.

name of Borrower

CERTIFICATE OF NO OBLIGATION
This is to declare under oath that the reflected Net Take Home Pay in my pay slip for the payroll period
has/have no obligation(s) and or is NOT amortized / allocated for any obligation from any Financial Institution.

ln case of no deduction reflected in my pay slip, I agree to personally pay my unpaid loan amortization to the bank until such time the
amortization will be reflected in my pay slip.
This is to further declare that I have no pending application for an indefinite leave of absence or transfer to another station, no plan to abroad
and not to cause any of these acts while my loan with 1$ VALLEY ., a Dqvelopment Bank is outstanding.

This is to further declare that any falsification in this me for the crime of perjury.

Signature name of Borrower

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printed name over printed name

Sketch / Location / Map of Residence:

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