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PWD ID Application Form 2023 - 2024

Pwd application

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HImantog Jay-ar
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308 views

PWD ID Application Form 2023 - 2024

Pwd application

Uploaded by

HImantog Jay-ar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CITY GOVERNMENT OF PASIG

PERSONS WITH DISABILITY AFFAIRS OFFICE


DEPARTMENT OF HEALTH
PHILIPPINE REGISTRY FOR PERSONS WITH DISABILITY VER. 4.0

□ NEW APPLICANT □ RENEWAL DATE APPLIED: ____________________

1. PWD NUMBER (RR-PPMM-BBB-NNNNNNN):


PLACE 1X1
2. LAST NAME: FIRST NAME: MIDDLE NAME: SUFFIX: PHOTO HERE

3. TYPE OF DISABILITY: (check all that apply) 4. CAUSE OF DISABILITY:

□ DEAF/HARD OF HEARING □ PSYCHOSOCIAL DISABILITY □ CONGENITAL/INBORN □ ACQUIRED


□ INTELLECTUAL DISABILITY □ SPEECH/LANGUAGE IMPAIRMENT □ AUTISM □ CHRONIC ILLNESS
□ LEARNING DISABILITY □ VISUAL DISABILITY □ ADHD □ CEREBRAL PALSY
□ MENTAL DISABILITY □ CANCER (RA-11215) □ DOWN SYNDROME □ INJURY
□ PHYSICAL DISABILITY □ RARE DISEASE (RA-10747)

5. ADDRESS: HOUSE NO. AND STREET NAME: BARANGAY:

CITY/MUNICIPALITY: PROVINCE: REGION:

6. CONTACT DETAILS:
LANDLINE: MOBILE NUMBER: EMAIL ADDRESS:

7. DATE OF BIRTH (mm/dd/yyyy) 8. SEX: 9. CIVIL STATUS


□ MALE □ SINGLE □ SEPERATED □ COHABITATION
□ FEMALE □ MARRIED □ WIDOW/ER (LIVE-IN)

10. EDUCATIONAL ATTAINMENT: 11. EMPLOYMENT STATUS: 12. OCCUPATION:


□ NONE □ EMPLOYED □ MANAGER
□ KINDERGARTEN □ UNEMPLOYED □ PROFESSIONAL
□ ELEMENTARY □ SELF EMPLOYED □ TECHNICIAN AND ASSOCIATE PROFESSIONALS
□ JUNIOR HIGH SCHOOL 11.1. CATEGORY OF EMPLOYMENT □ CLERICAL SUPPORT WORKERS
□ SENIOR HIGH SCHOOL □ GOVERNMENT □ SERVICE AND SALES WORKERS
□ COLLEGE □ PRIVATE □ SKILLED AGRICULTURAL, FORESTRY
□ VOCATIONAL AND FISHERY WORKERS
□ POST GRADUATE 11.2. NATURE OF EMPLOYMENT □ CRAFT & RELATED TRADE WORKERS
□ PERMANENT/REGULAR □ PLANT & MACHINE OPERATORS
□ CASUAL AND ASSEMBLERS
□ SEASONAL □ ELEMENTARY OCCUPATIONS
□ EMERGENCY □ ARMMED FORCES OCCUPATIONS
□ OTHER, SPECIFY: ____________________

13. BLOOD TYPE: 14. ORGANIZATION AFFILLIATED: 15. ID REFERENCE NO.


□ A+ □ AB+ Organization Affiliated: __________________ □ SSS NO. _______________________
□ A- □ AB- Contact Person: ________________________ □ GSIS NO. ______________________
□ B+ □ O+ Office Address: _________________________ □ PSN NO. _______________________
□ B- □ O- Tel No.: _______________________________ □ PHILHEALTH NO. ________________
□ Philhealth Member
□ Philhealth Member-Dependent
16. FAMILY BACKGROUND:
LAST NAME FIRST NAME MIDDLE NAME
FATHER’S NAME

MOTHER’S NAME

17. AACOMPLISHED BY: □ APPLICANT □ GUARDIAN □ REPRESENTATIVE

NAME: _____________________________________________________________________

18. NAME OF CERTIFYING PHYSICIAN: __________________________________ LICENSE NO: __________________________


19. NAME OF REPORTING UNIT: _______________________________________
20. CONTROL NO: __________________________________________________
21. PROCESSING OFFICER: ____________________________________________
22. APPROVING OFFICER: ____________________________________________
23. ENCODER: ______________________________________________________

APPLICATION FORM PWD NO. CTRL NO.

□ WALK IN □ BARANGAY □ ONLINE □ ENDORSED □ NEW □ RENEWAL □ LOST □ REPLACEMENT □ TRANSFER

NAME: __________________________________________ AGE: _____________ BARANGAY: ______________________


TYPE OF DISABILITY: _______________________________ DIAGNOSIS: __________________________________________
ADDRESS: ________________________________________ DATE OF BIRTH: ________________ GENDER: ____________
CONTACT NUMBER: _______________________________ (mm/dd/yyyy) (male/female)
EMAIL ADDRESS: __________________________________ MOTHER’S MAIDEN NAME: _____________________________

IN CASE OF EMERGENCY PLEASE NOTIFY:


NAME: _____________________________ RELATIONSHIP: _______________ CONTACT NUMBER: __________________

I __________________________________ resident of Barangay ____________________ Pasig City agreed to consent by


submitting this reply form; consent to the collection, generation, use, processing, storage and retention of my personal
data by PDAO for the purpose(s) described in this document. Please ensure that you have completely read and understood
the terms before signing. Any change will not be applied and will not alter how PDAO handles previously collected personal
data without obtaining your consent, unless required by law.

DATE: ______________________ SIGNATURE: _________________________

The Republic Act No. 10173, or the Data Privacy Act of 2012 (DPA), with the National Privacy Commission (NPC) overseeing its proper
implementation.

THIS FORM IS NOT FOR SALE (NO TRANSACTION FEE)

Online Application

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