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CAPITOL GOVERNMENT EMPLOYEES MULTI-PURPOSE COOPERATIVE

Provincial Administration Center, Gatuslao St., Bacolod City


Tel. No. 034-4762974; telefax 034-4355242

LOAN APPLICATION FORM

Applicant JOHN RAYMUND N. TANUGA Age 26 y.o. Birth date 6/1/1991 ID No. 0201066319

Dept/Office PROVINCIAL ENGINEER’S OFFICE Designation ENGINEERING ASSISTANT

Date Employed 02/01/2016 Employment Status: [x] Regular [ ] Contractual Basic Monthly P 15,818.00

Home Address: BRGY. II, SILAY CITY, NEGROS OCCIDENTAL Phone No: 09503266674

Type of Loan SALARY LOAN Amount of Loan Applied For P 30,000.00

Purpose of Loan HOUSE REPAIR TERMS: 2 YEARS

Certifying the above information is true and correct, I the undersigned hereby assign and offer as collateral for this
loan my salaries and wages, bonuses and other monetary and retirement benefits from the provincial government of Negros
Occidental / or my employer. I authorize CAPGEM, the Provincial Treasurer’s Office and/ or the paymaster designated by my
office / employer to deduct from my salary every payday any and all authorizations due on my loan including its interest and
other charges, if any. In case of my separation from service by reason of resignation, retirement and the like, I further
authorize the said office/ employer to withhold and deduct from whether or not the same already due and demandable.

_________________________________
MAKER/SIGNATURE OVER PRINTED NAME

Date Signed:______________________

SURETY’S UNDERTAKING

I, CLAIRE MARGARET ARCO a bonafide member of CAPGEM and a resident of BACOLOD CITY, NEGROS
OCCIDENTAL jointly and severally undertake the payment of the loan of JOHN RAYMUND N. TANUGA in the amount of
THIRTY THOUSAND PESOS ONLY (P 30,000) including its interest and other charges, if any. In this connection, I authorize
CAPGEM the Provincial Treasurer’s Office and/or paymaster designated by my office/employer to deduct from my salary
every payday all amounts due or demandable on the said loan.

_______________________________
SIGNATURE OVER PRINTED NAME

Date Signed:____________________

FOR CAPGEM USE

Membership Status Loan Granted


Maker [ ]Regular [ ] Associate [ ] APPROVED AMOUNT:
Surety/Co-Maker [ ]Regular [ ] Associate [ ] DISAPPROVED TERM:

EVALUATED/VERIFIED____________________________ BOARD OF DIRECTORS____________________________


CREDIT COMMITTEE ____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
PROMISSORY NOTE

Date: _______________________________

Date Due:____________________________

For the value received, I/We jointly and severally, promise to pay the Capitol Government Employees Multi-
Purpose Cooperative (CAPGEM) or order the sum of Pesos ______________________________________________(P
__________________) with interest thereon at the monthly rate of____________% payable as follows:

In case of default in payment as herein agreed, the entire balance of this note shall become immediately
due and payable, at the option of the holder. Each party to this note whether as maker, co-maker, endorser or
surety, severally waives presentation of payment, demand, protest and notice of protest and dishonor of the
same.

I/We agree that in case payment is not made at maturity, I/We be jointly and severally liable to pay the
cost of collection in an amount equal to twenty Per Cent (20%) of the principal and interest due on this note, but
in no case lower than Five Hundred Pesos (P500.00).

I/We further agree and authorize CAPGEM to encumber, assign or sell to any person or entity any right
which I/We may have under this note and/or assignment, mortgage, lieu, pledge, and other encumbrances
constituted in favor of CAMPGEM pursuant to the provisions of the loan agreement of this note, if any. The
consent herein granted is recognized and acknowledge by me/us as a waiver to all intents and purposes, of
whatever I/We may have to the notice of actual encumbrance or assignment.

MAKER: SURETY/CO-MAKER:

____________________________ ____________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME