Loyalty Card Application Form
ADVERTISEMENT
1
2HQP-PFF-108
LOYALTY CARD
Pag-IBIG MID NUMBER
APPLICATION FORM
REGISTRATION TRACKING NUMBER
(Privilege Card Program)
INSTRUCTIONS
1. Accomplish this form in one (1) copy.
4. Accomplish only the “PRESENT HOME ADDRESS” if it is different from the
2. Type or print all entries in BLOCK or CAPITAL LETTERS.
“PERMANENT HOME ADDRESS”
3. The “NAME EXTENSION” shall refer to JR., II, III and the like.
5. On “CONTACT DETAILS” portion, indicate at least one (1) contact number.
6. All fields which are marked with asterisk (*) are mandatory.
*MEMBERSHIP CATEGORY
Employed Private
Overseas Filipino Worker (OFW)
For Voluntary Members
Employed Government
Self-Employed (SE)
Employed
Employed Private Household
Other Working Group (OWG)
Individual Payor (IP)
Other Working Group (OWG), if income is less than P 1,000.00)
MEMBER’S PERSONAL DETAILS
*LAST NAME
*FIRST NAME
*NAME EXT.
*MIDDLE NAME
*MAIDEN NAME
(e.g., Jr., II)
(For married women)
*DATE OF BIRTH
*CITIZENSHIP
*MARITAL STATUS
TAXPAYERS IDENTIFICATION NUMBER (TIN)
-
-
Single/Unmarried
m m
d
d
y
y
y
y
Married
SSS/GSIS NUMBER
*PLACE OF BIRTH
*SEX
Widow/er
-
-
(City/Municipality/Province/Country)
Male
Annulled
(Please indicate country if born outside the Philippines)
Female
EMPLOYEE NUMBER
Legally Separated
*MOTHER’S MAIDEN NAME
For AFP/PNP Employee, Serial/Badge No.
For DepEd Employee, Division Code-Station Code
*NAME OF SPOUSE
(if married) (Last Name, First Name, Name Ext., Middle Name)
COMMON REFERENCE NUMBER (CRN/UMID)
ADDRESS AND CONTACT DETAILS
(Indicate country code if abroad)
*PERMANENT HOME ADDRESS
COUNTRY + AREA CODE + TELEPHONE NUMBER
Unit/Room No., Floor
Building Name
Lot No., Block No., Phase No. House No.
Street Name
Home
Subdivision
Barangay
Municipality/City
Province/State/Country (if abroad)
ZIP Code
*Cell Phone
*PRESENT HOME ADDRESS
Business (Direct Line)
Unit/Room No., Floor
Building Name
Lot No., Block No., Phase No. House No.
Street Name
Business (Trunk Line)
Local
Subdivision
Barangay
Municipality/City
Province/State/Country (if abroad)
ZIP Code
*Email Address
*PREFERRED MAILING ADDRESS
Present Home Address
Permanent Home Address
Employer/Business Address
PRESENT EMPLOYMENT DETAILS
(If with more than one (1) employer, use separate sheet and follow format below)
*EMPLOYER/BUSINESS NAME
MONTHLY INCOME RANGE
Less than P5,000
P5,000 to less than P15,000
P15,000 to less than P25,000
*EMPLOYER/BUSINESS ADDRESS
P25,000 to less than P35,000
Unit/Room No., Floor
Building Name
Lot No., Block No., Phase No. House No.
P35,000 to less than P50,000
P50,000 or more
Street Name
Subdivision
Barangay
*TYPE OF WORK
(For OFWs only)
Land-based
(Pls. specify country of assignment) _____________
Sea-based
Municipality/City
Province
*State/Country (if abroad)
ZIP Code
(Pls specify manning agency)__________________
*OCCUPATION
OFFICE ASSIGNMENT
*NATURE OF WORK/ BUSINESS/ SOURCE OF FUNDS
Head Office
Branch ____________
*EMPLOYMENT STATUS
*FROM
TO
Permanent/Regular
Part-Time/Temporary
Project-Based
Casual
Contractual
m
m
y
y
y
y
m
m
y
y
y
y
*PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG FUND MEMBERSHIP
(Use another sheet if necessary)
EMPLOYER/BUSINESS NAME
OFFICE ASSIGNMENT
Head Office
Branch ____________
1
EMPLOYER/BUSINESS ADDRESS
FROM
TO
m
m
y
y
y
y
m
m
y
y
y
y
EMPLOYER/BUSINESS NAME
OFFICE ASSIGNMENT
Head Office
Branch ____________
2
EMPLOYER/BUSINESS ADDRESS
FROM
TO
m
m
y
y
y
y
m
m
y
y
y
y
(Rev. 00, 02/2014)
THIS FORM MAY BE REPRODUCED. NOT FOR SALE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business