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

BUSINESS INFORMATION

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FARM INFORMATION

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ESTIMATED FARM INCOME PER YEAR

FARM ADDRESS

Address Line 1

City

State / Province / Region

Country

COOP/ASSOCIATION MEMBERSHIP

FARM SIZE/AREA

(No. of Hectares)

PLANTED

AVAILABLE FOR PLANTING

INVENTORY OF CROPS/LIVESTOCK

# OF TREES / LIVESTOCK

# OF PRODUCTIVE TREES / LIVESTOCK

# OF UN- PRODUCTIVE

OTHER CROPS / LIVESTOCK IN THE FARM (ENUMERATE)

VOLUME OF HARVEST PER YEAR (KG/PC)

OTHER CROPS/ LIVESTOCK (SPECIFY)

**PRODUCT FORM SOLD (SPECIFY)**

(Ex: Coconut- whole nut, buko, copra)

CROPS

LIVESTOCK

BUYER INFORMATION

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FOR CROPS

TRADER

COOPERATIVE / ASSOCIATION

OTHERS (PLEASE SPECIFY)

FOR LIVESTOCK

TRADER

COOPERATIVE / ASSOCIATION

OTHERS (PLEASE SPECIFY)

SOURCE OF FINANCING FOR FARMING

NON-FARM INCOME

COOPERATIVE

BANK & OTHER FINANCIAL INSTI.

OTHERS, SPECIFY

FINANCING AMOUNT

(ESTIMATE)

MAXIMUM

MINIMUM

POTENTIAL SUCCESSOR TO MANAGE THE FARM

YES
NO

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).