HQP-PFF-039

FOR Pag-IBIG Fund USE ONLY

MEMBERS DATA Pag-IBIG MID NUMBER

FORM (MDF) REGISTRATION TRACKING NUMBER

917216336425

INSTRUCTIONS
1. Accomplish this form in one (1) copy only. If registration is thru online, the 7. On the OCCUPATION portion, indicate occupation based on the List of
form should be printed back to back on one single sheet of paper. Occupation, as provided in the Philippine Standard Occupational Classification
2. Type or print all entries in BLOCK or CAPITAL LETTERS. (PSOC).
3. All fields which are marked with asterisk (*) are mandatory. 8. On the HEIRS portion, the provision on the Laws on Succession, as provided
4. On the OCCUPATIONAL STATUS portion, if without employment or purpose in the New Civil Code of the Philippines, as amended by the New Family Code,
is pre-employment or never been employed, select UNEMPLOYED/NOT YET shall be observed.
EMPLOYED. 9. For any subsequent change of information, please secure and accomplish
5. The NAME EXTENSION shall refer to JR., II, III and the like. Members Change of Information Form (MCIF, HQP-PFF-049) and submit to
6. Indicate the full name of your FATHER and MOTHER as they appear in your the concerned Pag-IBIG Branch.
birth certificate.

*OCCUPATIONAL STATUS EMPLOYED UNEMPLOYED/ NOT YET EMPLOYED

*MEMBERSHIP CATEGORY
MANDATORY
EMPLOYED PRIVATE EMPLOYED GOVERNMENT OVERSEAS FILIPINO WORKER (OFW) SELF-EMPLOYED (SE)
VOLUNTARY
EMPLOYED INDIVIDUAL PAYOR (IP)
EMPLOYED FOREIGN GOVERNMENT NON-WORKING SPOUSE PENSIONER/INVESTOR/LESSOR OTHERS
BARANGAY OFFICIAL/EMPLOYEE MEMBER OF RELIGIOUS GROUP MEMBER OF COOPERATIVE/TRADE UNION Please specify ________________
NAME
NO MIDDLE NAME
LAST NAME FIRST NAME EXTENSION MIDDLE NAME
(check if applicable only)
(e.g. Jr., II)

*MEMBER CONSON CHRISTIAN DISABELLE

FATHER CONSON LEODEGARIO GILDORE

*MOTHER (Maiden Name) CONSON CYNTHIA DISABELLE

*SPOUSE (If Married)

MEMBERS NAME AS
APPEARING IN THE BIRTH CONSON CHRISTIAN DISABELLE
CERTIFICATE
*DATE OF BIRTH *MARITAL STATUS TAXPAYER IDENTIFICATION NUMBER (TIN)
0 2 0 2 1 9 8 8 Single/Unmarried Widow/er Annulled
m m d d y y y y
Married Legally Separated
*PLACE OF BIRTH (City/Municipality/Province/Country) *CITIZENSHIP SSS/GSIS NUMBER
(Please indicate country if born outside the Philippines) 3 4 3 3 4 6 7 4 6 6
CEBU CITY, CEBU FILIPINO
*SEX HEIGHT WEIGHT PROMINENT DISTINGUISHING FACIAL FEATURES EMPLOYEE NUMBER
Male (Ex. Moles, Scars, etc.)
Female 158 (cm)
______ 68
______ (kg) For AFP/PNP Employee, Serial/Badge No.
COMMON REFERENCE NUMBER (CRN) FREQUENCY OF MEMBERSHIP SAVINGS (MS)
(If Available) PAYMENT (If payment of MS is not thru payroll deduction)
Monthly Semi-Annually For DepEd Employee, Division Code-Station Code
Quarterly Annually

ADDRESS AND CONTACT DETAILS

*PERMANENT HOME ADDRESS (Indicate country code if abroad)
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street Name Subdivision COUNTRY + AREA CODE TELEPHONE NUMBER
NONE PHASE 3 ARENDA
10B 8 3 10 Home
Barangay Municipality/City Province/State/Country (if abroad) ZIP Code
SAN JAUN SAN JUAN
1500 Cell Phone
*PRESENT HOME ADDRESS 0905 5201508
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No Street Name Subdivision
127 JV Business (Direct Line)
PANGANIBAN
Barangay Municipality/City Province/State/Country (if abroad) ZIP Code
ONCE SAN JUAN Business (Trunk Line) Local
1500

*PREFERRED MAILING ADDRESS Email Address

Present Home Address Permanent Home Address Employer/Business Address [email protected]
THIS FORM MAY BE REPRODUCED. NOT FOR SALE. (V05, 02/2016)
PRESENT EMPLOYMENT DETAILS (If with more than one (1) employer, use separate sheet and follow format below)
*EMPLOYER/BUSINESS NAME MONTHLY INCOME
Basic
+
Allowances/Others
*EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. =
Total Mo. Income

Street Name Subdivision Barangay *TYPE OF WORK (For OFWs only)

Land-based (Pls. specify country of assignment)
_____________________________
Sea-based (Pls. specify manning agency)
_____________________________
Municipality/City Province *State/Country (If abroad) ZIP Code OFFICE ASSIGNMENT
Head Office Branch ____________

*OCCUPATION *EMPLOYMENT STATUS *DATE EMPLOYED (Month, Year)

Permanent/Regular Contractual Part-time/Temporary
Casual Project-based

PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG Fund MEMBERSHIP (Use another sheet if necessary)

EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT

Head Office Branch ____________
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 ____________
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 ____________
EMPLOYER/BUSINESS ADDRESS FROM TO

m m y y y y m m y y y y
HEIRS (In case of death, Fund benefits shall be divided among the members heirs in accordance with the New Civil Code as amended by the New Family Code) (Use another sheet if necessary)

NAME NO MIDDLE NAME

LAST NAME FIRST NAME MIDDLE NAME RELATIONSHIP DATE OF BIRTH
EXTENSION (Check only if applicable)

m m d d y y y y

m m d d y y y y

m m d d y y y y

m m d d y y y y

I HEREBY CERTIFY THAT THE INFORMATION GIVEN AND ALL STATEMENTS MADE HEREIN ARE TRUE AND CORRECT.

_________________________________ 08/04/2017
_________________
SIGNATURE OF MEMBER DATE

FOR Pag-IBIG FUND USE ONLY

RECEIVED BY DATE

_________________________________ ________________________ ____________________

Signature over Printed Name Designation/Position Branch/Unit
DISCLAIMER: Membership registration with the Fund does not automatically qualify a Pag-IBIG member to avail of the Funds various loan
programs. A Pag-IBIG member must satisfy the eligibility requirements and comply with the documentary requirements, which is
subject to verification and approval.