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HQP-PFF-108 Loyalty Card Application Form

Pag-Ibig application form for loyalty card

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(V04, 01/2018)

LOYALTY CARD
APPLICATION FORM

Pag-IBIG MID NUMBER

(V01, 07/2017)

REGISTRATION TRACKING NUMBER

(Privilege Card Program)

_________________________________________________

INSTRUCTIONS
4. Accomplish only the “PRESENT HOME ADDRESS” if it is different from the
“PERMANENT HOME ADDRESS”
5. On “CONTACT DETAILS” portion, indicate at least one (1) contact number.
6. All fields which are marked with asterisk (*) are mandatory.

1. Accomplish this form in one (1) copy.
2. Type or print all entries in BLOCK or CAPITAL LETTERS.
3. The “NAME EXTENSION” shall refer to JR., II, III and the like.

*MEMBERSHIP CATEGORY
MANDATORY
 EMPLOYED PRIVATE
VOLUNTARY
EMPLOYED
 EMPLOYED FOREIGN GOVERNMENT
 BARANGAY OFFICIAL/EMPLOYEE

 EMPLOYED GOVERNMENT

 OVERSEAS FILIPINO WORKER (OFW)

 SELF-EMPLOYED (SE)

INDIVIDUAL PAYOR (IP)
 NON-WORKING SPOUSE
 MEMBER OF RELIGIOUS GROUP

 PENSIONER/INVESTOR/LESSOR
 OTHERS
Please specify____________
 MEMBER OF COOPERATIVE/TRADE UNION

MEMBER’S PERSONAL DETAILS
*LAST NAME

*FIRST NAME

*NAME EXT. (e.g., Jr., II) *MIDDLE NAME
*CITIZENSHIP

*DATE OF BIRTH
m m

d

d

y

y

y

*MAIDEN NAME (For married women)
TAXPAYERS IDENTIFICATION NUMBER (TIN)

y

*PLACE OF BIRTH
(City/Municipality/Province/Country)
(Please indicate country if born outside the Philippines)

*SEX
 Male
 Female

*MARITAL STATUS
Single/Unmarried
Married
Widow/er
Annulled
Legally Separated

-

-

SSS/GSIS NUMBER
-

-

EMPLOYEE NUMBER
For AFP/PNP Employee, Serial/Badge No.

*MOTHER’S MAIDEN NAME

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
*PERMANENT HOME ADDRESS
Unit/Room No., Floor

Building Name

Lot No., Block No., Phase No. House No.

Street Name

Subdivision

Barangay

Municipality/City Province/State/Country (if abroad)

(Indicate country code if abroad)
COUNTRY + AREA CODE + TELEPHONE NUMBER

ZIP Code

Home

*Cell Phone

*PRESENT HOME ADDRESS
Unit/Room No., Floor

Building Name

Lot No., Block No., Phase No. House No.

Street Name
Business (Direct Line)

Subdivision

Barangay

Municipality/City Province/State/Country (if abroad)

ZIP Code
Business (Trunk Line)

*PREFERRED MAILING ADDRESS
 Present Home
 Permanent Home
Address
Address

 Employer/Business
Address

 Claim at Pag-IBIG
Branch

Local

Local
*Email Address

PRESENT EMPLOYMENT DETAILS (if with more than (1) employer, use separate sheet follow format below)
*EMPLOYER/BUSINESS NAME

MONTHLY INCOME RANGE

*EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor

Building Name

Lot No., Block No., Phase No. House No.

Street Name

Subdivision

Barangay

Municipality/City

Province

*State/Country (if abroad)

*OCCUPATION

ZIP Code

*NATURE OF WORK/ BUSINESS/ SOURCE OF FUNDS

*EMPLOYMENT STATUS
Permanent/Regular
Casual

Less than P5,000
P5,000 to less than P15,000
P15,000 to less than P25,000
P25,000 to less than P35,000
P35,000 to less than P50,000
P50,000 or more
*TYPE OF WORK (For OFWs only)
Land-based
(Pls. specify country of assignment)
Sea-based
(Pls. specify manning agency)
OFFICE ASSIGNMENT
Head Office
FROM

Part-Time/Temporary Project-Based
Contractual

m m

d d

Branch
TO
y y y y

m m

d d

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

1

EMPLOYER/BUSINESS ADDRESS

Branch

FROM
m m

TO
d d

y y y y

m m

d d

y y y y

EMPLOYER/BUSINESS NAME
Head Office

2 EMPLOYER/BUSINESS ADDRESS

FROM
m m

MEMBER’S PER

Branch

THIS FORM MAY BE REPRODUCED. NOT FOR SALE

TO
d d

y y y y

m m

d d

y y y y

HQP-PFF-108
(V04, 01/2018)

*OTHER INFORMATION
HOME OWNERSHIP

WHAT ARE YOUR FUTURE PLANS
FOR YOUR HOME?

Owned, Mortgaged
Renting
Owned, Not Mortgaged
Living with Parents/Relatives

Buy/Loan for/Construct a House of
my Own
Improve/Extend my Current House
Continue to Rent/Live with Relatives

NO. OF YEARS IN RESIDENCE

NO. OF DOMESTIC TRAVELS
Once a Year
2 to 5 times per Year
More than 5 times per Year
Rarely
Never

Elementary
High School
College
Master/Ph.D.
Vocational___________

(V01, 07/2017)
NO. OF CHILDREN/DEPENDENTS
STILL STUDYING

NO. OF CREDIT CARDS OWNED

Other ___________________

NO. OF TRAVELS ABROAD
Once a Year
2 to 5 times per Year
More than 5 times per Year
Rarely
Never

EDUCATIONAL ATTAINMENT

NO. OF VEHICLES OWNED
NO. OF TIMES TO EAT AT A
RESTAURANT
Once a Month
2 to 5 times per Month
More than 5 times per Month
Rarely

NO. OF TIMES TO GO TO A MALL
Once a Month
2 to 5 times per Month
More than 5 times per Month
Rarely

AGREEMENT
I hereby certify that the information given and all statements made herein are true and correct. I agree that the information I have provided may be used or shared with third parties
conducting surveys, marketing activities or promotional offers of Pag-IBIG Fund and its partners. Any promotional offer of Pag-IBIG Fund may be emailed to me at the provided email
address. Any telephone calls I make to Pag-IBIG Fund may be monitored and recorded for the purpose of providing quality customer service. In case of falsification, misrepresentation
or any similar acts committed by the applicant Pag-IBIG Fund shall automatically suspend the benefits that can be secured through this card indefinitely.
I hereby agree to abide with the terms and conditions of this card program. I hereby agree to maintain my Pag-IBIG Fund membership status active and in good standing to enable me
to avail the benefits of this card program. In the event that I do not abide with the terms and conditions of this program, the Pag-IBIG Fund has the right to deny me of any benefit under
this card program.
I hereby authorize the Pag-IBIG Fund, its agents and representatives, upon application for any benefit relating to or under this card program, to conduct investigation deemed
appropriate to ascertain my credit standing and financial capability in evaluating availment of such benefit; including but not limited to, request consumer reporting or reference agencies
for consumer reports of my credit history and to disclose, submit, share or exchange any of my account information and reports to consumer reporting or reference agencies,
government regulatory agencies, other banks, merchant partners or third party. The Credit information may also be transferred to service providers such as TransUnion (TU), Bankers
Association of the Philippines – Credit Bureau, Credit Information Corporation, etc.
I hereby agree to the disclosures to be made by Pag-IBIG Fund in connection with this Agreement, provided the same are not contrary to law and public policy.
I hereby acknowledge that I shall bear the cost of my Loyalty Card and hereby allow my employer to collect from me or deduct from my salary the said amount, as payment for the said
card upon due notice from Pag-IBIG Fund. If the corresponding card fee remains unpaid, I hereby allow Pag-IBIG Fund to deduct from my Total Accumulated Value (TAV) the
corresponding card fee/s without prior notice.

SIGNATURE OF MEMBER

DATE

NOTE: If you do not wish to receive emails containing promotional offers or find any incorrect information, you may send an email at publicaffairs@pagibigfund.gov.ph or call Tel. (02) 724-4244.

THIS PORTION IS FOR Pag-IBIG LOYALTY CARD ENROLLMENT KIOSK USE ONLY

RECEIPT OF APPLICATION
APPLICATION THRU

TYPE OF ID PRESENTED

RECEIVED BY

DATE

REMARKS

DATE

REMARKS

IndividualEmployer

CONFIRMATION OF APPLICATION
PFR NO.

PFR AMOUNT

PFR DATE

CONFIRMED BY
 
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