HQP-PFF-039

FOR Pag-IBIG Fund USE ONLY

MEMBERS DATA
FORM (MDF)

Pag-IBIG MID NUMBER

8 0

REGISTRATION TRACKING NUMBER

913070182509

INSTRUCTIONS
1. Accomplish this form in one (1) copy only. If registration is thru online, the
form should be printed back to back on one single sheet of paper.
2. Type or print all entries in BLOCK or CAPITAL LETTERS.
3. All fields which are marked with asterisk (*) are mandatory.
4. On the OCCUPATIONAL STATUS portion, if without employment or purpose
is pre-employment or never been employed, select UNEMPLOYED/NOT YET
EMPLOYED.
5. The NAME EXTENSION shall refer to JR., II, III and the like.
6. Indicate the full name of your FATHER and MOTHER as they appear in your
birth certificate.

*OCCUPATIONAL STATUS

7. On the OCCUPATION portion, indicate occupation based on the List of

Occupation, as provided in the Philippine Standard Occupational Classification
(PSOC).
8. On the HEIRS portion, the provision on the Laws on Succession, as provided
in the New Civil Code of the Philippines, as amended by the New Family Code,
shall be observed.
9. For any subsequent change of information, please secure and accomplish
Members Change of Information Form (MCIF, HQP-PFF-049) and submit to
the concerned Pag-IBIG Branch.

EMPLOYED

UNEMPLOYED/ NOT YET EMPLOYED

*MEMBERSHIP CATEGORY

MANDATORY
EMPLOYED PRIVATE

EMPLOYED GOVERNMENT

OVERSEAS FILIPINO WORKER (OFW)

SELF-EMPLOYED (SE)

PENSIONER/INVESTOR/LESSOR

OTHERS
Please specify ________________

VOLUNTARY
EMPLOYED
EMPLOYED FOREIGN GOVERNMENT
BARANGAY OFFICIAL/EMPLOYEE

INDIVIDUAL PAYOR (IP)

NON-WORKING SPOUSE

MEMBER OF RELIGIOUS GROUP

DIVINIA

AVILA

AVILA

FLORENCIO

MERCADO

DISCAR

ANITA

BUCATCAT

VILLANUEVA

JORDAN JOSEPH

GARIANDO

AVILA

DIVINIA

DISCAR

*MOTHER (Maiden Name)

MEMBERS NAME AS
APPEARING IN THE BIRTH
CERTIFICATE

*DATE OF BIRTH
1

*MARITAL STATUS

Single/Unmarried
Married

mm dd yyyy

Widow/er
Legally Separated

Annulled

(check if applicable only)

TAXPAYER IDENTIFICATION NUMBER (TIN)

2

SSS/GSIS NUMBER

*PLACE OF BIRTH (City/Municipality/Province/Country) *CITIZENSHIP

(Please indicate country if born outside the Philippines)

FILIPINO

TACLOBAN CITY, LEYTE

HEIGHT
WEIGHT
*SEX
Male
______ (cm)
______ (kg)
Female
COMMON REFERENCE NUMBER (CRN)
(If Available)

NO MIDDLE NAME

MIDDLE NAME

(e.g. Jr., II)

VILLANUEVA

FATHER

*SPOUSE (If Married)

NAME
EXTENSION

FIRST NAME

LAST NAME
*MEMBER

MEMBER OF COOPERATIVE/TRADE UNION

PROMINENT DISTINGUISHING FACIAL FEATURES

(Ex. Moles, Scars, etc.)

CLIPCHIN

FREQUENCY OF MEMBERSHIP SAVINGS (MS)

PAYMENT (If payment of MS is not thru payroll deduction)
Monthly
Quarterly

Semi-Annually
Annually

EMPLOYEE NUMBER
0

For AFP/PNP Employee, Serial/Badge No.

For DepEd Employee, Division Code-Station Code

ADDRESS AND CONTACT DETAILS

*PERMANENT HOME ADDRESS
Unit/Room No., Floor

Building Name

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

Barangay

Municipality/City

Province/State/Country(if abroad)

171-F
BARANGAY 42

TACLOBAN CITY

*PRESENT HOME ADDRESS

Unit/Room No., Floor

Building Name

Barangay

Municipality/City
CATBALOGAN

CONGRESSMAN
MATE AVENUE

Subdivision

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

Street Name

CAMIA STREET

Province/State/Country(if abroad)

Subdivision
ZIP Code

6700

WESTERN SAMAR

*PREFERRED MAILING ADDRESS

Present Home Address

(Indicate country code if abroad)

COUNTRY + AREA CODE TELEPHONE NUMBER

Home

ZIP Code

6500

LEYTE

17
SAN PABLO

Street Name

Cell Phone
0936

5356612

Business (Direct Line)

055

5438070

Business (Trunk Line)

Local

Email Address

Permanent Home Address

Employer/Business Address

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.

[email protected]
(Rev. 03.1, 01/2015)

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

MONTHLY INCOME
Basic

LBC EXPRESS INCORPORATED

Allowances/Others

*EMPLOYER/BUSINESS ADDRESS

7,428.42
+

0.00

7,428.42

Unit/Room No., Floor

Building Name

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

Street Name

Subdivision

Barangay

*TYPE OF WORK (For OFWs only)

*State/Country (If abroad)

Land-based (Pls. specify country of assignment)

_____________________________
Sea-based (Pls. specify manning agency)
_____________________________
OFFICE ASSIGNMENT

Total Mo. Income

MAHARLIKA
HIGHWAY
Municipality/City

Province

TACLOBAN CITY

LEYTE

*OCCUPATION

Sales Representatives, Services, All Other

*EMPLOYMENT STATUS
Permanent/Regular
Casual

Contractual
Project-based

ZIP Code

6500

Branch ____________

Head Office

*DATE EMPLOYED (Month, Year)

Part-time/Temporary

May 2009

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

EMPLOYER/BUSINESS NAME

OFFICE ASSIGNMENT

EMPLOYER/BUSINESS ADDRESS

FROM

EMPLOYER/BUSINESS NAME

OFFICE ASSIGNMENT

TO
y

Head Office

Branch ____________

Branch ____________
TO

FROM
m

TO

Head Office
EMPLOYER/BUSINESS ADDRESS

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)
LAST NAME
AVILA

FIRST NAME
ANITA

NAME
EXTENSION

MIDDLE NAME

NO MIDDLE NAME

(Check only if applicable)

RELATIONSHIP

MOTHER

DISCAR

DATE OF BIRTH

0 2

1 9

9 4 9

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

_________________________________

12/8/2016

_________________

SIGNATURE OF MEMBER

DATE

FOR Pag-IBIG FUND USE ONLY

RECEIVED BY

DATE

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.