Membership Profiling for Farmers and Entrepreneurs

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BRANCH *

DATE

MEMBER'S INFORMATION

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LAST NAME *

FIRST NAME *

MIDDLE NAME *

SPOUSE NAME:

(LN, FN, MN)

ACTIVE CONTACT NO *

GENDER *

AGE *

RELIGION *

ADDRESS *

Address Line 1

City

State / Province / Region

Country

HIGHEST EDUCATIONAL ATTAINMENT: *

COLLEGE GRADUATE
SECONDARY EDUCATION
ELEMENTARY EDUCATION
VOCATIONAL

ETHNICITY

FARM INFORMATION

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Commodity/Crop

FARM ADDRESS

Address Line 1

City

State / Province / Region

Country

COOP/ASSOCIATION MEMBER

Yes
No

FARM SIZE/AREA

(No. of Hectares)

AREA PLANTED

UNPLANTED AREA

OTHER CROPS (SPECIFY)

LIVESTOCK (SPECIFY)

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BUYER INFORMATION

TRADER
COOP/ASSOCIATION
OTHERS:

SOURCE OF FINANCING FOR FARMING

TRADER
COOP/ASSOCIATION
OTHERS:

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FINANCING AMOUNT

(ESTIMATE)

POTENTIAL FARM SUCCESOR

Yes
No

BUSINESS INFORMATION

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Credit Information System Act (CISA) Compliance. *

I hereby affirm that the information given by me is true and correct. I authorized you to verify and investigate it from whatever sources you may consider appropriate. I also confirm and acknowledge that the above information and those which may arise as needed, is voluntary provided to Bansalan Multipurpose Cooperative (BansalanCoop) pursuant to RA 9510 otherwise known as Credit Information System Act (CISA).