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    Application Form For Coop Membership

    Uploaded by

    Francis Jay Enriquez
    This document is an application form for membership in the Mindoro Occidental Medical Mission Group Health Service Cooperative. It requests personal information such as name, contact details, educational background, professional affiliations, and capital contribution schedule. The applicant pledges to pay their subscribed capital in installments, participate in cooperative activities, and promote the cooperative's goals. They may also be asked to serve on committees. Requirements for membership include identification documents and photos. Physician applicants must also submit diplomas and training certificates.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application Form For Coop Membership

    Uploaded by

    Francis Jay Enriquez
    168 views4 pages
    This document is an application form for membership in the Mindoro Occidental Medical Mission Group Health Service Cooperative. It requests personal information such as name, contact details, educational background, professional affiliations, and capital contribution schedule. The applicant pledges to pay their subscribed capital in installments, participate in cooperative activities, and promote the cooperative's goals. They may also be asked to serve on committees. Requirements for membership include identification documents and photos. Physician applicants must also submit diplomas and training certificates.

    Original Title

    APPLICATION FORM FOR COOP MEMBERSHIP

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    This document is an application form for membership in the Mindoro Occidental Medical Mission Group Health Service Cooperative. It requests personal information such as name, contact details, educational background, professional affiliations, and capital contribution schedule. The applicant pledges to pay their subscribed capital in installments, participate in cooperative activities, and promote the cooperative's goals. They may also be asked to serve on committees. Requirements for membership include identification documents and photos. Physician applicants must also submit diplomas and training certificates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    168 views4 pages

    Application Form For Coop Membership

    Uploaded by

    Francis Jay Enriquez
    This document is an application form for membership in the Mindoro Occidental Medical Mission Group Health Service Cooperative. It requests personal information such as name, contact details, educational background, professional affiliations, and capital contribution schedule. The applicant pledges to pay their subscribed capital in installments, participate in cooperative activities, and promote the cooperative's goals. They may also be asked to serve on committees. Requirements for membership include identification documents and photos. Physician applicants must also submit diplomas and training certificates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    MINDORO OCCIDENTAL MEDICAL MISSION GROUP

    HEALTH SERVICE COOPERATIVE


    Diego Silang St., San Jose, Occidental Mindoro

    APPLICATION FORM FOR COOP MEMBERSHIP


    (Please fill up this form completely and write legibly)

    I, __________________________________, Filipino, of legal age, hereby depose and say: THAT below are
    my PERSONAL DATA:

    Name (last, first, middle/maiden) : ____________________________________________________________


    Birthdate: ________________________________ Birthplace: __________________________________________
    Residence and Tel. #: ___________________________________________________________________________
    Office and Tel. #: ______________________________________________________________________________
    Mailing Address: ______________________________________________________________________________
    E-mail Address: ____________________________ Cellular #: ___________________________________________
    Profession: ___________________________________________________________________________________
    Specialty: _________________________________ Subspecialty: ________________________________________
    Present Job/Position: ___________________________________________________________________________
    Any Cooperative Affiliation: _____________________________________________________________________
    Spouse: _____________________________________________________________________________________

    Name of Children/Dependent Birthdates


    ____________________________________________ _________________________________________________
    ____________________________________________ _________________________________________________
    ____________________________________________ _________________________________________________
    ____________________________________________ _________________________________________________
    ____________________________________________ _________________________________________________

    EDUCATIONAL BACKGROUND
    College (school/course/year graduated): ___________________________________________________________
    ____________________________________________________________________________________________
    Vocational (school/course/year graduated): ________________________________________________________
    _____________________________________________________________________________________________
    Postgraduate/MD degree/year: ___________________________________________________________________
    ______________________________________________________________________________________________

    ADDITIONAL INFORMATION FOR PHYSICIANS:

    Internship : ____________________________________________ Year : ___________________________


    Residency : ____________________________________________ Year : ___________________________
    Fellowship : ___________________________________________ Year : ___________________________

    Hospital Affiliations : __________________________________________________________________________


    Membership in Medical Societies: ________________________________________________________________

    PMA No. : ___________________________________


    PHIC No.: __________________________________
    PRC ID No.: ________________________________
    MINDORO OCCIDENTAL MEDICAL MISSION GROUP
    HEALTH SERVICE COOPERATIVE
    Diego Silang St., San Jose, Occidental Mindoro

    THAT I pledge to pay the remaining 75% of my subscribed capital either by:

    ( ) ___ postdated checks (maximum of 6 months)


    ( ) Automatic salary deduction for 6 month salary
    ( ) Automatic deduction from Professional Fee for ___ (max of 6) months
    ( ) To be paid by my cooperative or corporate account
    ( ) Extended payments beyond 6 months; 2% monthly interest to be added after the
    6th month to remaining amount due, paid in full with postdated checks
    ( ) I have already paid my subscribed capital in full amount
    ( ) Others: _________________________________________

    THAT
    ( ) I have no health-related business that will constitute conflict of interest with MMG
    ( ) My health-related business/investments are as follows; (state content of owner-
    ship investment)
    ___________________________________________________________________
    ___________________________________________________________________

    THAT
    My personal interests include; _______________________________________________
    __________________________________________________________________________

    THAT
    ( ) I could be tapped to work on the following committees: (check all that applies)
    { } Credit { } Election
    { } Audit/Inventory { } Membership
    { } Any Committee
    ( ) I don’t wish to work under any committee

    And THAT my duties and responsibilities as a member are to:

    a. Pay the installment of my share capital subscription as it falls due; to participate in the
    capital build-up and savings mobilization activities of the Cooperative;
    b. Patronize the Cooperative’s business and services;
    c. Participate in the membership education programs;
    d. Attend and participate in the deliberation of all matters taken during general assembly
    meetings:
    e. Observe and obey all lawful orders, decisions, rules & regulations adopted by the
    Board of Directors and the General Assembly:
    f. Promote the goals and objectives of the cooperative, the success of its business, the
    welfare of the members and the cooperative movement in general

    Signature of Applicant : ________________________________________


    MINDORO OCCIDENTAL MEDICAL MISSION GROUP
    HEALTH SERVICE COOPERATIVE
    Diego Silang St., San Jose, Occidental Mindoro

    Date Signed : ________________________________________

    Community Tax Certificate No. : ________________________________________

    Date Issued : ________________________________________

    Place of Issue : ________________________________________

    TIN : ________________________________________

    ------------------------------------------------------------------------------------------------------------------------------------------------

    For Applicant’s to Associate Membership:

    Name of Member-Endorser : _________________________________________

    Signature of member-Endorser : _________________________________________

    Relationship to Member-Endorser : ____________________________________________

    ---------------------------------------------------------------------------------------------------------------------------------------------------------------

    DO NOT WRITE BELOW [ For use of Membership Committee Members only]

    [ ] Approved as: [ ] Regular Member


    [ ] Preferred shareholder (Associate)

    [ ] Disapproved (state reasons for disapproval): _____________________________________________


    ____________________________________________________________________________________

    [ ] Pending (state reasons): _______________________________________________________________


    ____________________________________________________________________________________

    Received by: ____________________________________________ Date: ____________________________________

    Approved by: ___________________________________________ Date: ____________________________________

    Signed:

    _____________________________________________ _______________________________________

    _____________________________________________ _______________________________________
    MINDORO OCCIDENTAL MEDICAL MISSION GROUP
    HEALTH SERVICE COOPERATIVE
    Diego Silang St., San Jose, Occidental Mindoro

    ANNEX I

    I am subscribing _____ shares which are equivalent to Php ________ (Php 100/share), of which I a
    m paying 25% of my subscribed capital. My schedule of payment for my subscribed capital would be as follow:
    1st payment: _________________ Php__________________
    2nd payment: _________________ Php__________________
    3rd payment: __________________ Php__________________
    4th payment: __________________ Php __________________
    5th payment: __________________ Php__________________
    6th payment: _________________ Php__________________

    Requirements:
    1) Birth Certificate of dependents and/or
    2) Marriage Certificate and,
    3) Proof of Billing OR
    4) Any Identification Proof with your address AND
    5) 1x1 picture
    6) Long folder

    FOR PHYSICIANS(in addition to above requirements):


    1) Diploma from Medical School
    2) Certificate of Residency Training
    3) Certificate of Fellowship or Diplomate (if any)
    4) Photocopy of PRC Id
    5) Long Folder

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