HQP-PFF-108

(V07, 11/2021)

LOYALTY CARD PLUS Pag-IBIG MID NUMBER (V01, 07/2017)

APPLICATION FORM
1 0 2 0 5 7 8 9 1 1 2 0
ISSUING PARTNER-BANK

INSTRUCTIONS
1. Accomplish this form in one (1) copy. 5. Accomplish only the “PRESENT HOME ADDRESS” if it is different from the
2. Present at least one (1) valid ID acceptable to the Pag-IBIG Fund. “PERMANENT HOME ADDRESS”
3. Type or print all entries in BLOCK or CAPITAL LETTERS. 6. On “CONTACT DETAILS” portion, indicate at least one (1) contact number.
4. The “NAME EXTENSION” shall refer to JR., II, III and the like 7. All fields which are marked with asterisk (*) are mandatory

*MEMBERSHIP CATEGORY
MANDATORY VOLUNTARY

X EMPLOYED (PRIVATE)  SELF-EMPLOYED  EMPLOYED (FOREIGN GOVERNMENT)  MEMBER OF COOPERATIVE/
 EMPLOYED (GOVERNMENT)  PROFESSIONAL/BUSINESS OWNER  BARANGAY OFFICIAL/EMPLOYEE TRADE UNION
 EMPLOYED PRIVATE HOUSEHOLD  JOB ORDER PERSONNEL  NON-WORKING SPOUSE  OVERSEAS FILIPINO IMMIGRANT
 OVERSEAS FILIPINO WORKER  OTHER EARNING GROUPS  MEMBER OF RELIGIOUS GROUP  OTHERS, Please specify
(OFW) (OEG)  PENSIONER/INVESTOR/LESSOR _________________________

MEMBER’S PERSONAL DETAILS

*LAST NAME *FIRST NAME *NAME EXT. (e.g., Jr., II) *MIDDLE NAME *MAIDEN NAME (For married women)
DELA CRUZ JUAN JR MAGNO N/A
*DATE OF BIRTH *CITIZENSHIP *MARITAL STATUS TAXPAYERS IDENTIFICATION NUMBER (TIN)
Single/Unmarried
X 1 2 1 - 6 7 3 - 4 1 5
1 0 1 2 1 9 9 0 FILIPINO Married
m m d d y y y y Widow/er SSS/GSIS NUMBER
Annulled 3 3 - 4 1 8 6 7 2 - 8 0
*PLACE OF BIRTH *SEX
Legally Separated EMPLOYEE NUMBER
(City/Municipality/Province/Country)  Male
X
(Please indicate country if born outside the Philippines)  Female
QUEZON CITY For AFP/PNP Employee, Serial/Badge No.
*MOTHER’S MAIDEN NAME
EVANGELINE PEDRO MAGNO For DepEd Employee, Division Code-Station Code

*NAME OF SPOUSE (if married) (Last Name, First Name, Name Ext., Middle Name)
COMMON REFERENCE NUMBER (CRN)
N/A - - -
ADDRESS AND CONTACT DETAILS
*PERMANENT HOME ADDRESS (Indicate country code if abroad)
Unit/Room No., Floor Lot No., Block No., Phase No. House No. Street Name Subdivision COUNTRY + AREA CODE + TELEPHONE NUMBER
Home
38 BLOCK 250 LOT 5 MARANG ST
Barangay Municipality/City Province/State/Country ZIP Code
(if abroad) *Cell Phone
PEMBO MAKATI CITY 1201 632 9187745618
*PRESENT HOME ADDRESS Business (Direct Line)
Unit/Room No., Floor Lot No., Block No., Phase No. House No. Street Name Subdivision
38 BLOCK 250 LOT 5 MARANG ST
Business (Trunk Line) Local
Barangay Municipality/City Province/State/Country ZIP Code
(if abroad) Local
PEMBO MAKATI CITY 1201 [email protected]
*Email Address: __________________________________

PRESENT EMPLOYMENT DETAILS (if with more than (1) employer, use separate sheet and follow format below)
*EMPLOYER/BUSINESS NAME Monthly Income Range
Less than P5,000
IFIVE INC P5,000 to less than P15,000
*EMPLOYER/BUSINESS ADDRESS P15,000 to less than P25,000
Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. P25,000 to less than P35,000
P35,000 to less than P50,00
8/F Zeta Tower, Robinsons Bridgetowne,
P50,000 or more
Street Name Subdivision Barangay *OCCUPATION
C5 Road Ugong Norte Call Center Representative
Municipality/City Province *State/Country (if abroad) ZIP Code *NATURE OF WORK/ BUSINESS/ SOURCE OF
FUNDS
Quezon City 1110
Salary
*EMPLOYMENT STATUS

Permanent/Regular
X Casual Contractual Project-Based Part-Time/Temporary

*PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG FUND MEMBERSHIP (Use another sheet if necessary)
EMPLOYER/BUSINESS NAME
CONCENTRIX
1 EMPLOYER/BUSINESS ADDRESS FROM TO
01 01 2 0 1 9 0 6 1 3 2 0 1 9
QUEZON CITY m m d d y y y y m m d d y y y y
EMPLOYER/BUSINESS NAME
TELEPERFORMANCE
2 EMPLOYER/BUSINESS ADDRESS FROM TO
0 6 2 0 2 0 1 9 0 8 2 6 2 02 1
EDSA SHAW BLVD. PASIG CITY m m d d y y y y m m d d y y y y
MEMBER’S PER
THIS FORM MAY BE REPRODUCED. NOT FOR SALE
 HQP-PFF-108
(V07, 11/2021)

*OTHER INFORMATION
(V01, 07/2017)
STATUS OF HOME OWNERSHIP FUTURE PLANS ON HOME OWNERSHIP


Owned

X Purchase a Residential Unit through Personal
Renting
Fund
Living with Parents/Relatives
Mortgaged Avail of a Loan for Purchase of Residential Unit
Pag-IBIG Fund or Construction of House
Banks and Other Financial Institution Renovate the current house through availment of
loan
If mortgaged with Bank or other Financial Institution, are you interested to transfer your
Loan to Pag-IBIG Fund? Continue to rent
Continue to live with parents/relatives
_____Yes _____No
DESIRED LOAN AMOUNT (IF INTERESTED WITH HOW MUCH CAN YOU AFFORD IN TERMS OF EDUCATIONAL ATTAINMENT
PAG-IBIG FUND FINANCING) MONTHLY PAYMENT FOR HOUSING LOAN?
Less than P750,000 Elementary
Less than P5,000 per month High School
P750,000 up to P1,700,000 P5,000 to less than P10,000 per month College/Bachelor’s Degree
Above P1,700,000 up to P3,000,000 P10,000 to less than P15,000 per month Master's/Doctoral Degree
Above P3,000,000 up to P6,000,000 P15,000 and above per month Vocational

NO. OF CHILDREN/DEPENDENTS NO. OF VEHICLES OWNED ESTABLISHMENT YOU WISH TO BE A Pag-IBIG

STILL STUDYING LOYALTY CARD PARTNER

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, including the terms and conditions of the card and the privacy policy of the accredited Partner-Bank. 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. Likewise, I hereby authorize the Fund, to disclose, submit or share my account information to the
accredited Partner-Bank for the purpose of account opening and other bank transactions and in compliance with the Know-Your-Client requirements of the Bangko Sentral ng Pilipinas
(BSP) and R.A. No. 10173 (Data Privacy Act of 2012). I agree to advise the Partner-Bank in writing of any change in the above information.

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.

JUAN DELA CRUZ 05/03/2022

SIGNATURE OF MEMBER DATE
NOTES:
1. If you do not wish to receive emails containing promotional offers or find any incorrect information, you may send an email at [email protected] or call Tel. (02) 8724-4244.
2. Your Pag-IBIG Loyalty Card Plus is not a government-issued I.D., but may be used in all Pag-IBIG Fund transactions.
3. If your mode of payment is through Deduction from Loan Proceeds, no cash payment shall be collected.

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

RECEIPT OF APPLICATION
MODE OF PAYMENT APPLICATION THRU TYPE OF ID PRESENTED

CASH
 DEDUCTION FROM LOAN INDIVIDUAL EMPLOYER
PROCEEDS

RECEIVED BY DATE REMARKS




LIST OF VALID IDs ACCEPTABLE TO THE Pag-IBIG FUND/BANKS

10. Social Security System (SSS) Card

1. Passport
11. Senior Citizen Card 17. Certification from the National Council for the
2. Driver’s License
12. Overseas Workers Welfare Administration Welfare of Disabled Persons (NCWPD)
3. Professional Regulation Commission (PRC) ID
(OWWA) ID 18. Department of Social Welfare and Development
4. National Bureau of Investigation (NBI) Clearance
13. Overseas Filipino Worker ID (DSWD) Certification
5. Police Clearance
14. Seaman’s Book or Seafarer’s Identification and 19. Integrated Bar of the Philippines ID
6. Postal ID
Record Book (SIRB) 20. Philippine Identification (PhilID) Card
7. Voter’s ID
15. Alien Certification of Registration/Immigrant 21. Company ID issued by Private Entities or
8. Barangay Certificate or Barangay IDs or similar
Certificate of Registration Institutions Registered with or supervised or
documents bearing picture of the Member
16. Government Office and GOCC ID, e.g. AFP ID regulated either by the BSP, SEC or IC
9. Government Services Insurance System (GSIS)
Pag-IBIG Fund Loyalty Card and Loyalty Card
e-Card
Plus (in case of recarding)