0905-970-2301

LESTER LADIA 0991-926-0748

06272205
CODE: 0339 / New Loan
Registry No. Reloan
SALARY LOAN APPLICATION FORM Voucher No. Multiple
Date:
Instructions: PLEASE PRINT ALL INFORMATION LEGIBLY IN CAPITAL LETTERS. Indicate N/A in the fields which are not applicable.

I hereby apply for a loan in the amount of PESOS: _______________________________________________________________________________________ (P_____________________) for the following purpose:

Training/Education / Home Renovation Others (please specify) ____________________________________

Household
Medical Loan Buyout
Consumption/Needs
for a term of: _________________________ months, which I promise to pay in accordance with the rules, regulations, terms and conditions of CITY SAVINGS BANK as stipulated in this application form, the Promissory Note of
even date, and such other documents executed together with this loan; all of which I certify to have read and understood clearly.

PERSONAL INFORMATION

Client Name (Last Name, Given and Middle Name) / Single Married
Civil Status
ROXAS, JOANA, TOLENTINO Widowed Separated
Date of Birth
(mm/dd/yyyy) 11/23/1979 Birth Place MONTALBAN, RIZAL Sex Male / Female

Age 44 CTC No. Mobile No. 09695180639

Nationality FILIPINO GSIS/SSS No. 3347397046 Res. Tel. No. N/A

Email Address [email protected] TIN 214566270

Present Address (No./Street/Village/Barangay/District/Municipality/City/Town/Province) Zip Code

29 COL. S. CRUZ ST. BALITE MONTALBAN, RIZAL 1860

Owned / Living with Parents Company Quarters Mortgaged Length of Stay 44 Years
______ 09 Months
______
Ownership
Living with Relatives Rented Others (specify): ___________________ Res. Tel. No.

Permanent Address (No./Street/Village/Barangay/District/Municipality/City/Town/Province) Zip Code

29 COL. S. CRUZ ST. BALITE MONTALBAN, RIZAL 1860

Owned / Living with Parents Company Quarters Mortgaged Length of Stay 44 Years
______ 09 Months
______
Ownership
Living with Relatives Rented Others (specify): ___________________ Res. Tel. No.

EMPLOYMENT INFORMATION
Name of
DEPED RIZAL - SAN RAFAEL ELEMENTARY SCHOOL/CASILI ELEMENTARY SCHOOL Office Tel. No. & Local (02) 8284 2070
Employer/School
Address of
SAN RAFAEL, MONTALBAN, RIZAL Office Mobile No. 0922 432 9999
Employer/School

Source of Fund SALARY Employee No. 6466576 Office Email Address [email protected]

Position ADMINISTRATIVE OFFICER II Div Code 043 Basic Monthly Salary PHP 27,000.00

Human Resource Management & Monthly Recurring

Nature of Work Reg Code 04A PHP 2,000.00
Supply Management Allowance

Employment Status PERMANENT Station Code 010 Date Hired JANUARY 15, 2024
SPOUSE INFORMATION (IF APPLICABLE)

Spouse’s Name (Last Name, Given and Middle Name) Date of Birth

N/A Birth Place

Employer/Business Age

Position Mobile No.

Nature of Work/ Business Monthly Income USD/PHP Email Address

IN THE EVENT OF THE APPROVAL OF MY APPLICATION FOR SALARY LOAN AND BANK: UnionBank CitySavings
ANY REFUNDABLES THAT IS DUE TO ME, I HEREBY AUTHORIZE CITY SAVINGS
BANK TO CREDIT THROUGH MY GSIS – UNIONBANK UMID/ECARD OR
CITYSAVINGS SAVINGS ACCOUNT (SA22). Signature over Printed Name of the Borrower Account #:

PRIVATE INFORMATION PROVISIONS FOR LOAN APPLICATION

The loan applicant (“Borrower”) acknowledges and agrees that, in the course of his/her loan application with (c) to any consultant, adviser, auditor, counsel, agent, contractor or sub-contractor of CitySavings performing
City Savings Bank, Inc. (“CitySavings”), and throughout the term of his/her loan if such loan application is services for the purpose of assisting or rendering services to CitySavings in the administration or promotion of its
granted, CitySavings may receive or have access to Personal Information and/or Sensitive Personal lending business;
Information and/or any financial information of the Borrower which CitySavings may consider as relevant in (d) to any person to whom CitySavings proposes to assign or transfer of its rights and/or duties to the loan;
evaluating the loan application (hereinafter collectively referred to as “Private Information.”) Borrower (e) to any guarantor or person providing security in relation to Borrower’s obligation;
expressly consents to the processing, collection, transmission, storage, disposal, use and disclosure of (f) as required or permitted by law, regulation, court or any regulatory authority; or
Private Information by CitySavings for the following purposes: (g) as otherwise considered necessary or appropriate by CitySavings.

“Personal Information” as used herein means information provided to CitySavings by or at the direction of
(a) to manage Borrower’s account(s), including endorsement to outsourced collections service provider in Borrower, or to which access was provided to CitySavings by or at the direction of Borrower wherein: (i) the
case of default, any consultant, adviser, auditor, counsel, agent, contractor or sub-contractor of CitySavings identity of an individual is apparent or can be reasonably and directly ascertained; or (ii) when put together with
performing services for the purpose of assisting or rendering services to CitySavings in the administration or other information, would directly identify an individual.
promotion of its lending business;
(b) to confirm, update and enhance CitySavings’ records; “Sensitive Personal Information” as used herein means any Personal Information that: (i) pertains to an
(c) for statistical analysis, internally by CitySavings and/or any service provider it may engage for the individual’s race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations; (ii)
purpose; pertains to an individual’s health, education, genetic or sexual life, or to any proceedings in court; (iii) is issued by
(d) to establish any identity or otherwise as required under applicable legislation; government agencies peculiar to an individual, e.g., social security numbers and health records; or (iv) is
(e) to assess Borrower’s credit status on an on-going basis; specifically established by an executive order or an act of Congress to be kept classified.
(f) for marketing and promotional of CitySavings products; or
(g) any other purpose, as considered necessary or appropriate by CitySavings Furthermore by signing this form, the Borrower understands and expressly waives his/her right under
confidentiality laws including but not limited to RA 1405 or The Law on Secrecy of Bank Deposits, RA 6426 or The
In each case, the processing of Private Information may continue after the termination of the loan Foreign Currency Deposit Act and RA 8791 or the General Banking Law and their respective implementing rules
agreement. CitySavings may disclose the Borrower’s Private Information: and regulations and allow processing, storing, access to or sharing of any information regarding the
aforementioned Salary Loan as well as the Bank products, services and channels which the Depositor has
(a) to a credit reference agency where it may be accessed by other financial institutions to assist assessment activated, enrolled in or availed pursuant to this Form.
of any application for credit made to CitySavings and for debt tracing and fraud prevention;
(b) to its parent company or any of its affiliate or subsidiary;
JOANA T. ROXAS
CONFORME: ____________________________________________

Signature over Printed Name of the BORROWER

——————————DO NOT WRITE BELOW THIS SPACE-FOR CITYSAVINGS USE ONLY——————————

Complete required
RPSU AUTONOMOUS Newly hired with permanent appointment
documents
NET PAY VALIDATION: (3 mos. Latest Original Payslips) LOAN INFO REDEMPTION

1. Month Php Branch Name: PLI Name: Php

2. Month Php Branch SOL ID: PLI Name: Php

3. Month Php Scheme Code: PLI Name: Php

Group Code: SERVICING

 Branch Name Scheme Code:

Application received and verified by: Date:

LOAN COMMITTEE:

Date Received

Remarks AMOUNT APPROVED

Ph
p
only

TERM (in months)

Name
Ph
We recommend a loan of P p
Date:

be granted for a period of / months

Recommended by:

REFERRER’S PERSONAL INFORMATION (OPTIONAL)

REFERRER (1)
Employee No./ID
Name in Print: Contact No.:
No.:
REFERRER (2)
Employee No./ID
Name in Print: Contact No.:
No.:
REFERRER’S CONSENT
Referrer consents to the processing of personal information by the City Savings 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,City Savings.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.) City Savings Bank, Inc., Union Bank of the Philippines, Petnet;inc., Aboitiz Equity Venture and respective subsidiaries, affiliates and; related interests {the "Aboitiz;Group");
(ii.) service providers outsourced by the Bank ;
(iii) such other persons or entities that the Bank or any member of the Aboitiz Group, may deem necessary to perform the above activities.

Shall hold the CitySavings,Bank,lnc. and each member of the Aboitiz 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: ____________________________________________

Signature over Printed Name of the REFERRER (1)

CONFORME: ____________________________________________

Signature over Printed Name of the REFERRER (2)

SIGNED IN THE PRESENCE OF (CITYSAVINGS USE ONLY)

Signature over Printed Name Signature over Printed Name

For complaints, you may do either of the following: approach the Consumer Protection and Assistance Officer of the day in the branch where you did the transaction, text hotline 0917-8746753 or email to [email protected]. Rest
assured that we will address them the soonest possible time.