The document is an application form for accreditation with the Social Security System of the Philippines. It requests information about a cooperative including its name, address, date of operation, number of members, contact information, type of cooperative, nature of business, and names and identification numbers of authorized signatories and president. The applicant certifies the information is true. The form also includes instructions for submitting required supporting documents such as articles of cooperation, by-laws, financial statements, and lists of officers, creditors, and members. Upon approval, the cooperative will be assigned a business code and allowed to collect and remit members' social security contributions.

1. Republic of the Philippines
SOCIAL SECURITY SYSTEM
(12-2010)
APPLICATION FOR ACCREDITATION
Please read instructions at the back before accomplishing this form. Print all information in capital letters and use black ink only.
PART I - APPLICANT'S INFORMATION
NAME OF COOPERATIVE EMPLOYER ID NUMBER
PRINCIPAL OFFICE ADDRESS (Room/Floor/Bldg No./Name) (Street)
(Subdivision/Village) (Barangay/District/Locality)
(City/Municipality) (Province)
START OF OPERATION (mm/dd/yyyy) NUMBER OF MEMBERS COOPERATIVE ID NUMBER CATEGORY
Primary Secondary Tertiary
TELEPHONE NUMBER FAX NUMBER E-MAIL ADDRESS ( IF ANY)
(AREA CODE) (AREA CODE)
TYPE OF COOPERATIVE CREDIT CONSUMERS PRODUCERS MARKETING
SERVICE MULTIPURPOSE OTHERS: (Specify) ______________________________________
NATURE OF BUSINESS AREA OF OPERATION
NAME OF AUTHORIZED SIGNATORY SS NUMBER/CRN
(Last Name) (First Name) (Middle Name)
OFFICIAL DESIGNATION:
NAME OF PRESIDENT/CHAIRMAN SS NUMBER/CRN
(Last Name) (First Name) (Middle Name)
PART II - CERTIFICATION
I certify that the information provided in this form are true and correct.
SIGNATURE OVER PRINTED NAME OFFICIAL DESIGNATION DATE
PART III - TO BE FILLED OUT BY SSS BRANCH
POSTAL CODE DATE OF COVERAGE (mm/yyyy) BUSINESS CODE RECEIVING BRANCH
REMARKS
SCREENED BY
PRINTED NAME SIGNATURE DATE
PART IV - TO BE FILLED OUT BY INVESTMENT RESEARCH AND SUPPORT DEPARTMENT
CAPITALIZATION: CURRENT RATIO: QUICK RATIO: RECEIVED BY/DATE:
REMARKS
EVALUATED BY:
PRINTED NAME SIGNATURE DATE

2. INSTRUCTIONS/REMINDERS
1. Fill out this form in two (2) copies and accomplish Parts I & II.
2. Submit this form to the nearest SSS branch having jurisdiction over its operation.
3. This application shall be submitted with the following documents:
a. Articales of Cooperation
b. By-Laws
c. Economic Survey (which is a general statement describing the structure, purpose, economic feasibility of the proposed cooperative, area of
operation, size of membership and other pertinent data)
d. Certificate of Registration with the Cooperative Development Authority
e. A favorable endorsement, issued not earlier than six (6) months prior to the time of filing the application, from the proper government agency
in case of cooperatives engaged in the following activities:
Activity Government Agency
Air Transport Civil Aeronautics Board
Bangko Sentral ng Pilipinas
Banking, Pawnshop & other financial
intermediacies with quasi-banking functions
Professional Boxing Games & Amusement Board
Operation of games of chance Philippine Charity Sweepstakes Office
Educational Institution (college or tertiary Commission on Higher Education
course)
Educational Institution (elementary to high Department of Education
school)
Educational Institution (technical or
vocational) Technical and Skills Development Authority
Electric Power Plants Department of Energy
Hospitals Department of Health
Insurance Insurance Commission
Land Transport Land Transportation Franchising and
Regulatory Board
W t t t t ti d b ildi Maritime Industry Authority
Water transport construction and building of M iti I d t A th it
vessels
Operation of radio, television and telephone National Telecommunications Commission
Recruitment for Overseas Employment Philippine Overseas Employment
Administration
Security Agency Philippine National Police
Philippine National Police
Manufacture, repair, storage and/or
distribution of products and/or ingredients of
firearms, gun powder and all those indicated
in Executive Order No. 95.s 2002 Foreign
Investment Negative List
Department of National Defense
Manufacture, repair, storage and/or
distribution of products, i.e., guns,
ammunition for warfare, military and all those
indicated in Executive Order No. 95.s 2002
Foreign Investment Negative List
f. List of names and addresses of the present members of its Board of Directors
g. The Board Resolution, duly certified by the cooperative secretary, approving the Collection Agency Agreement (CAA) and particularly naming
the officer as the authorized signatory thereto
h. Audited financial statements for the last three (3) years
i. Names and addresses of accountable officers to be bonded, and the estimated amount of coverage of the bond
j. Proposed nature of the bond to secure its performance under the CAA, and the estimated amount of coverage of the bond
k. List of all of the cooperative’s creditors and their addresses and the corresponding nature, amount and terms of obligations
l. Certificate of Registration with the SSS
m. List of members who are Self-employed or Voluntary Members of the SSS and their corresponding Social Security (SS) number, and
individual statement allowing the cooperative to collect and remit their contributions to the SSS