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GSIS UMID Application Form NEW ENROLLEE
GSIS UMID Application Form NEW ENROLLEE
PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN (GOVERNMENT SERVICE INSURANCE SYSTEM) Financial Center, Roxas Boulevard, Pasay City 1308 GSIS UMID-eCARD ENROLLMENT FORM
(NEW ENROLLEE)
PLEASE CHECK THE TYPE OF MEMBER ACTIVE OLD AGE PENSIONER SURVIVORSHIP PENSIONER LEGAL GUARDIAN
MEMBERS INFORMATION
Personal Information
First Name Middle Name Last Name Suffix (i.e., Sr., Jr., III, etc.) Maiden Name (if married female employee) Date of Birth (DD-MM-YYYY) Place of Birth-City Place of Birth-Province Place of Birth-Country (if born outside of the Philippines) Marital Status Gender *GSIS ID No. (the 11 digit number below your name in the eCard)
Fathers Information
First Name Middle Name Last Name Suffix (i.e., Sr., Jr., III, etc.)
Additional Information
Distinguishing Features Office Name Height (in centimeter) Office Address Weight (in kilogram)
Certified By: __________________________________________________________ Signature of Member/Pensioner over Printed Name and Date _______________________________________ (For active Member) Signature of AAO
GSIS PORTION
Validated by: Date: Enrolled by: Date:
ANNOTATION
I hereby certify that the member/applicant named above is physically impaired and no biometrics can be captured. ______________________________________ Printed Name of Enrolment Officer / Date