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ECRD-2010-01-001 GSIS UMID-e Card Enrollment Form
GSIS application form for umid-e card
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: GSIS Form No. ECRD-2010-01-001
Date Revised: 2013-06-14
Central Office/Branch Office
Central Office/Branch Office Address
GSIS UMID-eCard ENROLLMENT FORM
Please use BLOCK or CAPITAL LETTERS in filling out the form. Use pen with blue or black ink.
MEMBER'S INFORMATION
Personal Information
Residence Address/Contact Information
Last Name
Room/Floor/Unit No & Building Name (if applicable)
First Name
House or Lot and Block No.
Middle Name
Street Name
Suffix (i.e. Sr, Jr, III, etc.)
Subdivision
Maiden Name (if married female)
Brgy/District/Locality
Date of Birth (YYYY-MM-DD)
Municipality/City
Place of Birth-Country
Province
Place of Birth-Province
Postal Zip Code
Place of Birth-Municipality/City
Home Phone No. (Area Code+No)
Gender
Mobile/Cellphone No.
Marital Status
Office Phone No. (Area Code+No)
Email Address
Tax Identification No (TIN)
Country
Office Name
Office Address
Father's Name
Mother's Maiden Name
Last Name
Maiden Last Name
First Name
First Name
Middle Name
Maiden Middle Name
Suffix (i.e. Sr, Jr, III, etc)
Suffix (i.e. Sr, Jr, III, etc)
ADDITIONAL INFORMATION
Height in cm (Conversion: 1 ft = 12 in or 30.48 cm; 1in = 2.54 cm)
Weight in kg (Conversion: 1 kg = 2.2 lbs)
Prominent Facial Features (mole, birthmark, scars, etc)
PREFERRED SERVICING BANK
Upon issuance of Common Reference Number (CRN), I understand that GSIS will print my UMID eCard in accordance with my preferred bank as indicated below. (Please indicate
preference with a ''.)
Union Bank of the Philippines (UBP)
Land Bank of the Philippines (LBP)
LBP Br Code/Branch
STATEMENT OF CONSENT
I declare that I am fully aware that the above data shall be used for securing my Common Reference Number (CRN) for the Unified Multi-Purpose ID (UMID) System or updating my personal data and
that it shall form part of the CRN Registry. I trust that the above data shall remain confidential hence I give my consent that the same data be secured and accessed for subsequent validation,
verification, and other purposes consistent with the objectives of the UMID System under Executive Order No. 420 as amended by Executive Order No. 700. I further affirm that all statements/data,
which appear in this registration form and made by me are true and complete to the best of my knowledge and belief.
Date Signed
Signature Over Printed Name
TO BE ACCOMPLISHED BY GSIS ENROLMENT OFFICERS
Business Partner No. (10-digit number)
GSIS ID No. (the 11-digit number below your name in the eCard)
Common Reference No. (12-digit number)
Enrolment Status:
Active Member
EC Disability Pensioner
Survivorship Pensioner
Old Age Pensioner
EC Survivorship Pensioner
Legal Guardian of survivorship beneficiaries
(minors, mentally i
( i
t ll incapacitated, etc)
it t d t )
IDs Presented:
1)
Ecard No.
2)
3)
Others
1)
4)
2)
5)
Validated By:
Enrolled By:
Date:
Date:
CERTIFICATION
I hereby certify that the enrollee herein is physically impaired and that the following cannot be captured:
Signature
Biometrics
Name and Signature of Enrolment Officer
Picture
Others
Name and Signature of Witness (relative or companion of enrollee)
