"Unified Multi-Purpose ID (Umid) Card Application Form" - Philippines

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Republic of the Philippines
UNIFIED MULTI-PURPOSE ID (UMID) CARD
APPLICATION FORM
(07-2013)
THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED
CAPITAL LETTERS
USE BLACK OR
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN
AND
BLUE INK ONLY
.
NAME OF AGENCY
COMMON REFERENCE NUMBER
(IF ANY)
SOCIAL SECURITY SYSTEM
PURPOSE
INITIAL ENROLLMENT
CARD REPLACEMENT
Replacement of Lost Card
Amendment of Facts of Birth
Others ____________________
Amendment of Demographic Data
Replacement of Damaged Card
__________________________
Amendment of Name
Amendment of Authenticating Finger
PART I - NAME
1. NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
MAIDEN NAME
(IF MARRIED FEMALE)
PART II - FACTS OF BIRTH
2. DATE OF BIRTH
3. PLACE OF BIRTH
(CITY/MUNICIPALITY)
(PROVINCE/STATE)
(COUNTRY, If born outside the Philippines)
4. SEX
(MMDDYYYY)
MALE
FEMALE
5a. FATHER'S NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
5b. MOTHER'S MAIDEN NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
PART III - DEMOGRAPHIC DATA
6. HOME ADDRESS
(RM./FLR./UNIT NO. & BLDG. NAME)
(HOUSE/LOT & BLK. NO.)
(STREET NAME)
(SUBDIVISION)
(BARANGAY/DISTRICT/LOCALITY)
(CITY/MUNICIPALITY)
(PROVINCE/STATE)
ZIP CODE
COUNTRY CODE
7. MARITAL STATUS
SINGLE
MARRIED
WIDOWED
DIVORCED/ANNULED
LEGALLY SEPARATED
8.
TAX IDENTIFICATION NUMBER
9. HEIGHT
10. WEIGHT
11. DISTINGUISHING FEATURE(S)
(IN CENTIMETERS)
(IN KILOGRAMS)
(IF ANY)
PART IV - 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 in 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 purpose consistent with the objectives
of the UMID System under Executive Order No. (EO) 420 as amended by EO No. 700. I further affirm that all statements/data, which appear in
this application form and made by me are true, correct and complete to the best of my knowledge and belief.
PRINTED NAME
SIGNATURE
DATE
PART V - OTHER ENROLLEE DATA
TELEPHONE NUMBER
MOBILE/CELLPHONE NUMBER
E-MAIL ADDRESS
SS NUMBER
(AREA CODE + TEL. NO.)
IF YOU ARE A SURVIVING SPOUSE/GUARDIAN/DEPENDENT OF DECEASED/PENSIONER MEMBER, PLEASE INDICATE SS NUMBER/COMMON REFERENCE
NUMBER (IF ANY) OF DECEASED/PENSIONER MEMBER BELOW
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
SS NUMBER/COMMON REFERENCE NUMBER
NAME OF MEMBER
PART VI - FOR SSS USE ONLY
IDENTIFICATION/DOCUMENT/S PRESENTED
REMARKS
SCREENED BY
DATA CAPTURED BY
SIGNATURE OVER PRINTED NAME
DATE & TIME
BRANCH
SIGNATURE OVER PRINTED NAME
DATE & TIME
-------------------------------------------------------------------------------------------------Perforate Here-------------------------------------------------------------------------------------------------
Republic of the Philippines
UNIFIED MULTI-PURPOSE ID (UMID) CARD APPLICATION FORM
ACKNOWLEDGEMENT STUB
NAME OF AGENCY
BRANCH
SS NUMBER/COMMON REFERENCE NUMBER
SOCIAL SECURITY SYSTEM
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
NAME
SCREENED BY
DATA CAPTURED BY
SIGNATURE OVER PRINTED NAME
DATE & TIME
SIGNATURE OVER PRINTED NAME
DATE & TIME
Perforate here
RIGHT THUMB
RIGHT INDEX
Republic of the Philippines
UNIFIED MULTI-PURPOSE ID (UMID) CARD
APPLICATION FORM
(07-2013)
THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED
CAPITAL LETTERS
USE BLACK OR
PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN
AND
BLUE INK ONLY
.
NAME OF AGENCY
COMMON REFERENCE NUMBER
(IF ANY)
SOCIAL SECURITY SYSTEM
PURPOSE
INITIAL ENROLLMENT
CARD REPLACEMENT
Replacement of Lost Card
Amendment of Facts of Birth
Others ____________________
Amendment of Demographic Data
Replacement of Damaged Card
__________________________
Amendment of Name
Amendment of Authenticating Finger
PART I - NAME
1. NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
MAIDEN NAME
(IF MARRIED FEMALE)
PART II - FACTS OF BIRTH
2. DATE OF BIRTH
3. PLACE OF BIRTH
(CITY/MUNICIPALITY)
(PROVINCE/STATE)
(COUNTRY, If born outside the Philippines)
4. SEX
(MMDDYYYY)
MALE
FEMALE
5a. FATHER'S NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
5b. MOTHER'S MAIDEN NAME
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
PART III - DEMOGRAPHIC DATA
6. HOME ADDRESS
(RM./FLR./UNIT NO. & BLDG. NAME)
(HOUSE/LOT & BLK. NO.)
(STREET NAME)
(SUBDIVISION)
(BARANGAY/DISTRICT/LOCALITY)
(CITY/MUNICIPALITY)
(PROVINCE/STATE)
ZIP CODE
COUNTRY CODE
7. MARITAL STATUS
SINGLE
MARRIED
WIDOWED
DIVORCED/ANNULED
LEGALLY SEPARATED
8.
TAX IDENTIFICATION NUMBER
9. HEIGHT
10. WEIGHT
11. DISTINGUISHING FEATURE(S)
(IN CENTIMETERS)
(IN KILOGRAMS)
(IF ANY)
PART IV - 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 in 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 purpose consistent with the objectives
of the UMID System under Executive Order No. (EO) 420 as amended by EO No. 700. I further affirm that all statements/data, which appear in
this application form and made by me are true, correct and complete to the best of my knowledge and belief.
PRINTED NAME
SIGNATURE
DATE
PART V - OTHER ENROLLEE DATA
TELEPHONE NUMBER
MOBILE/CELLPHONE NUMBER
E-MAIL ADDRESS
SS NUMBER
(AREA CODE + TEL. NO.)
IF YOU ARE A SURVIVING SPOUSE/GUARDIAN/DEPENDENT OF DECEASED/PENSIONER MEMBER, PLEASE INDICATE SS NUMBER/COMMON REFERENCE
NUMBER (IF ANY) OF DECEASED/PENSIONER MEMBER BELOW
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
SS NUMBER/COMMON REFERENCE NUMBER
NAME OF MEMBER
PART VI - FOR SSS USE ONLY
IDENTIFICATION/DOCUMENT/S PRESENTED
REMARKS
SCREENED BY
DATA CAPTURED BY
SIGNATURE OVER PRINTED NAME
DATE & TIME
BRANCH
SIGNATURE OVER PRINTED NAME
DATE & TIME
-------------------------------------------------------------------------------------------------Perforate Here-------------------------------------------------------------------------------------------------
Republic of the Philippines
UNIFIED MULTI-PURPOSE ID (UMID) CARD APPLICATION FORM
ACKNOWLEDGEMENT STUB
NAME OF AGENCY
BRANCH
SS NUMBER/COMMON REFERENCE NUMBER
SOCIAL SECURITY SYSTEM
(LAST NAME)
(FIRST NAME)
(MIDDLE NAME)
(SUFFIX)
NAME
SCREENED BY
DATA CAPTURED BY
SIGNATURE OVER PRINTED NAME
DATE & TIME
SIGNATURE OVER PRINTED NAME
DATE & TIME
Perforate here
RIGHT THUMB
RIGHT INDEX
INSTRUCTIONS
1. This form shall be used in applying for initial or replacement UMID card.
2. Fill out this form in one (1) copy without erasures and alterations.
3. Place a checkmark on the applicable box.
4. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
5. Present identification document/s.
a. Any one (1) of the following primary documents:
Driver's License
▪ Professional Regulation Commission (PRC) card
▪ Passport
▪ Seaman's Book
b.
In the absence of the primary documents, submit any two (2) of the following secondary documents, one of which with signature and photo:
Postal ID
▪ Marriage Contract
School or Company ID
▪ NBI Clearance
Taxpayer's Identification Number (TIN) card
▪ Pag-IBIG Member's Data Form
▪ Permit to Carry Firearms issued by the Firearms & Explosive Unit of PNP
Membership Card issued by private companies
Overseas Worker Welfare Administration Card
▪ PHIC Member's Data Record
Senior Citizen Card
▪ Police Clearance
Voter's Identification Card/Affidavit/Certificate of Registration
Seafarer's Registration Certificate issued by the Philippine Overseas
ATM card
Employment Authority (POEA)
▪ Temporary License issued by Land Transportation Office (LTO)
- with cardholder's name
- with certification from bank, if without name
▪ Transcript of School Records
▪ Credit card
▪ Alien Certificate of Registration
Fisherman's Card issued by the Bureau of Fisheries and
▪ Bank Account Passbook
Aquatic Resources (BFAR)
▪ Certificate from:
GSIS Card/Member's Record/Certificate of Membership
- Office of the Southern/Northern Cultural Communities
▪ Health or Medical Card
- Office of Muslim Affairs
ID Card issued by LGUs (e.g. Barangay/ Municipal/City)
Certificate of Licensure/Qualification Documents/Seafarer's ID & Record
ID Card issued by professional association recognized by PRC
Book from Maritime Industry Authority
▪ Certificate of Naturalization from the Bureau of Immigration
▪ Permanent Residency ID
▪ Birth Certificate
▪ Life Insurance Policy
▪ Baptismal Certificate
▪ Birth/Baptismal certificate of child/ren or its equivalent
6. Fill out appropriate items in the following format:
a. Items 1, 5a and 5b
Example: Juan Andres Gregorio Toralba III will be entered as:
b. Item 1 (For Married Female)
Example: Anna Maria Dela Cruz Santos at birth and married name is Anna Maria Roman will be entered as:
c. Item 6
Example: 837 Akle St., Barangay Claro, Project 2, Quezon City 1102 will be entered as:
Indicate the permanent address rather than the temporary mailing address. For example, if with permanent residence in the province but
working or staying in Metro Manila during weekdays, indicate the provincial address instead of the Metro Manila address.
Write the "Height" in centimeters and "Weight" in kilograms.
7.
To convert:
1 ft = 30.38 cm
1 lb = 0.4536 kg
1 in = 2.54 cm
8.
In item 11, limit the distinguishing features to those that can be found on the face such as "mole under the right eye" and "mole or birth mark on the
left cheek/forehead".
9.
For card replacement, pay the required fee at any SSS branch office/accredited bank/collecting agent and submit this form together with the required
document/s and validated Miscellaneous Payment Form or Special Bank Receipt (SBR) with Miscellaneous Payment Form to the nearest SSS branch
office.
10. For card replacement due to amendment of data/authenticating finger, submit the previously issued SSS or UMID card.
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