Originating Branch

Teachers Loan Application Form Account Officer

Date of Application

New Loan New Loan with Takeout Reloan Reloan with Takeout
INSTRUCTION: PLEASE PRINT ALL INFORMATION LEGIBLY IN CAPITAL LETTERS. Write N/A in the fields which are not applicable
LOAN APPLICATION DETAILS
Are you currently a Cebuana Lhuillier Bank Requested Loan Amount Loan Term (months) Loan Purpose
client? YES NO PERSONAL CONSUMPTION

PERSONAL INFORMATION
Name of First Name (Pangalan) Middle Name (Gitnang Pangalan) Last Name (Apelyido) Suffix
Applicant

Date of Birth (Araw ng Kapanganakan) Age (Edad) Place of Birth (lugar ng kapanganakan) Nationality (Nasyonalidad) SSS or GSIS No. TIN
(mm/dd/yyyy)

Gender (Kasarian) Civil Status Email Address Mobile No. Postpaid Prepaid Residence Phone No.
Male Female Single Widow
Married Legally Separated
Present Address (Check box if this is your mailing address)
No./Street Village/Subd Brgy City/Municipality Province Zip Code

Residential Status Residing Since (Taon ng Paninirahan) Educational Attainment (Antas ng Pinag-aralan) No. of Cars Owned
Owned (not mortgaged) Rented Used Free High School College Others
Owned (mortgaged) Living with relatives Vocational Post Graduate ______________

Provincial or Permanent Address (Check box if this is your mailing address)

No./Street Village/Subd Brgy City/Municipality Province Zip Code

FINANCIAL INFORMATION
Name of Employer/School Office/School Tel. No.

Address of Employer/School Office/School Mobile No.

No./Street Brgy City/Municipality/Province Zip Code

Source of Income Employee No Office/School Email Address

Position Station Code Gross Monthly Income (PHP)

Nature of Work Division Code Other Source of Income (PHP)

Employment Status Region Code Monthly Household Expense

Date Hired PRC ID No. (For Teaching Personnel) No. of Dependents

SPOUSE INFORMATION (IF APPLICABLE)

Spouse's Name (Pangalan ng Asawa) Date of Birth (mm/dd/yyyy)

Birth Place
Present Address (Check box if this is your mailing address)
No./Street Brgy City/Municipality/Province Zip Code
Age Nationality

Provincial Or Permanent Address (Check box if this is your mailing address) Residence Mobile No. Postpaid Prepaid
No./Street Brgy City/Municipality/Province Zip Code

Employer/Business Name (Pangalan ng kumpanyang pinapasukan o ng sariling kumpanya) Length of Stay (Taon ng Paninirahan) Email Address

Employer/Business Address (Lugar ng hanapbuhay o negosyo) Educational Attainment

No./Street Brgy City/Municipality/Province Zip Code
High School College Others:
Vocational Post Graduate
Position Employment Status Source of Income Type of ID ID No.

Nature of Work/Business Years Operating Gross Monthly Income (PHP/USD) Other Source of Income

WORK OR PERSONAL REFERENCES

Name of Reference Address Relationship/Position Contact No. (Tel or Mobile No.)

------ FOR BANK'S USE ONLY ----

CLIENT TYPE PAYROLL TYPE WORK CATEGORY
Walk in MVP Referral Social Media RPSU Teaching
Marketed by AO Referred by Other Employee Others, please specify Autonomous Non-Teaching
DOC CHECKLIST Remarks
FOR TAKE OUT (As Applicable) Payslip(s)
PLI 1 Balance (PHP) Appointment Letter
PLI 2 Balance (PHP) IDs Presented
PLI 3 Balance (PHP) Evaluation Sheet
PLI 4 Balance (PHP) Verification Result
PLI 5 Balance (PHP) Disbursement Instruction
SOA (Takeout)
Others (Specify)
 RESIDENCE SKETCH/MAP

CONSENT AND UNDERTAKING

1. The Borrower hereby certifies that the provided information are true and correct and shall form part of the loan documents and the signatures indicated herein are genuine. Such information includes, but is not
limited to the following:
(a) That the presented payslip is original, correct and complete and that no hidden charges or data is omitted from it;
(b) That the said payslip is not tampered or forged;
(c ) That all my loan amortization including future amortizations from other creditors, if any, are reflected in the payslip and/or disclosed to CLRB Representative
(d) That all disclosed data in the Loan Application Form is true and correct
The Borrower's or his authorized representative's provision of any information which is not true or updated may cause Cebuana Lhuillier Rural Bank (CLRB) to automatically reject the Borrower's loan application
or cancel its approval.
2. While the loan obligation is still outstanding, the borrower agrees and undertakes to inform Cebuana Lhuillier Rural Bank, Inc. of any changes in employment status that will affect the loan arrangement with the said
bank such as, but not limited to the following:
(a) Transfer of assignment from one school to another;
(b) Filing of resignation or retirement, or
(c) That
Any all
formmyofloan
termination
amortization
of employment
including future amortizations from other creditors, if any, are reflected in the payslip and/or disclosed to CLRB Representative
3. The borrower agrees and undertakes to make over-the-counter payments of all amortizations due if not deducted by the Automatic Payroll Deduction System (APDS) of DepEd or Disbursement Office of the
Autonomous School for any reasons.
4. The Borrower authorizes CLRB to obtain relevant information as it may require concerning this application from other institutions/persons. All information obtained by or provided to CLRB pursuant to this application
shall be CLRB's property whether or not the loan is granted.
5. The Borrower agrees that this loan application shall be subject to applicable laws (including BSP circulars, rules and regulations), and policies of CLRB and undertakes to comply with/submit all loan requirements.
6. The Borrower hereby waives in favor of CLRB confidentiality of client information including without limitation, the provisions of Republic Act Nos. 1405 (The Law on Secrecy of Bank Deposits), 6426 (Foreign Currency
Deposit Act), and Section 55.1.b of Republic Act No. 8791 (General Banking Law) and any law relating to the secrecy of bank deposits for purposes of CLRB's evaluation of the Borrower's application herein. The
Borrower authorizes CLRB to: (a) pursuant to BSP Circular No. 472 Series of 2005 as implemented by BIR Revenue Regulation RR-4 2005, conduct random verification with the Bureau of Internal Revenue in order to
establish authenticity of the ITR, accompanying financial statements and such other documents/information/data submitted by the Borrower, and/or (b) obtain or disclose such information regarding the Borrower or
the loan/credit facilities applied for hereunder to any party as CLRB may deem necessary or as may be required or allowed by applicable laws. The Borrower also authorizes CLRB to request information regarding the
status of any court case to which the Borrower is a party.
7. In case of disapproval, the Borrower understands that CLRB is under no obligation to disclose the reason/s for such disapproval.
8. The Borrower further certifies that the proceeds of the loan, if this application is approved, will be used solely for the purpose stated in this application.
9. The Borrower hereby authorizes CLRB to contact the Borrower regarding the status of the Borrower's loan application, details concerning the Borrower's approved/ availed loan via e-mail, telephone, text message,
etc. Further, the Borrower authorizes CLRB and its affiliates, and their respective representatives and agents ("PJ Lhuillier Group") to provide support information notices, offers and announcements for the purpose of
marketing, cross selling and sales offers to the Borrower via email, as well as broadcast messaging service, multi-media messaging service, and/or short messaging service as these terms are defined in the regulations of
the National Telecommunications Commission (NTC). The Borrower agrees to hold CLRB free and harmless against any loss, injury or damage that the Borrower may suffer in relation to any notification/announcement
sent by CLRB to the Borrower in the format stated herein. It is agreed and understood that unless and until CLRB is in receipt of written notice from the Borrower not to be sent such messages, the Borrower's authority
as given herein shall be deemed continuing, valid and effective.
10. In the event of the approval of loan application for salary loan and any refundables, the borrower hereby authorizes Cebuana Lhuillier Rural Bank to credit to the borrower's nominated depository account.

APPLICANT SIGNATURE OVER Date

PRINTED NAME
REFERRER'S INFORMATION & CONSENT
Name MVP Number Contact Number

Referrer consents to the processing of personal information by the Cebuana Lhuillier Rural Bank, Inc., its directors, officers, employees, advisers, consultants, auditors, agents and representatives for purposes of (i) carrying
out,management, performance and development of its products and services (ii) pursuit of its marketing; promotional, communication, commercial and research objectives;-(iii) usual business transactions and (iv) compliance with the
requirements of applicable laws and/or government regulators or supervisory bodies. This constitutes as express consent under the applicable confidentiality and data privacy laws of the Philippines given, by the Referrer specifically
allows the, Cebuana Lhuillier Rural Bank, Inc. to:
(a) collect, use, record, store, consolidate, retrieve, and process ("process") of Information;
(b) outsource the processing of Information to service providers wherever located.
(c) verification or validation of Information from any and all sources and In any reasonable manner
(d) disclose and share the information or data to:
(i.) Cebuana Lhuillier Rural Bank, Inc., and affiliates and; related interests {the "P.J. Lhuillier Group of Companies");
(ii.) service providers outsourced by the Bank ;
(iii) such other persons or entities that the Bank or any member of the PJ Lhuillier Group, may deem necessary to perform the above activities.
shall hold the Cebuana Lhuillier Rural Bank,lnc. and each member of the PJ Lhuillier Group, free and harmless from any and all liabilities, claims, damages and suits of whatever kind and nature, that may arise" in connection with the
performance of the activities related with the authorization conferred by the Referrer hereunder.

CONFORME: Date
Signature over Printed Name of the Referrer

------ FOR BANK'S USE ONLY ----

RECEIVED BY DATE RECEIVED BY DATE