HQP-PFF-039

FOR Pag-IBIG Fund USE ONLY

MEMBERS DATA
FORM (MDF)

Pag-IBIG MID NUMBER

REGISTRATION TRACKING NUMBER

916047217598

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

EMPLOYED

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.

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

MEMBER OF COOPERATIVE/TRADE UNION

NAME
EXTENSION

FIRST NAME

LAST NAME

NO MIDDLE NAME

MIDDLE NAME

(check if applicable only)

(e.g. Jr., II)

*MEMBER

BALAS

WILGIN

DAMILES

FATHER

BALAS

WILSON

MALIN

DAMILES

GINA

LAURIE

BALAS

WILGIN

DAMILES

*MOTHER (Maiden Name)

*SPOUSE (If Married)
MEMBERS NAME AS
APPEARING IN THE BIRTH
CERTIFICATE

*DATE OF BIRTH
0

*MARITAL STATUS

Single/Unmarried
Married

mm dd yyyy

TAXPAYER IDENTIFICATION NUMBER (TIN)

Widow/er
Legally Separated

Annulled

SSS/GSIS NUMBER

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

(Please indicate country if born outside the Philippines)

SERGIO OSMEA, ZAMBOANGA DEL NORTE

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

FILIPINO
PROMINENT DISTINGUISHING FACIAL FEATURES

EMPLOYEE NUMBER

(Ex. Moles, Scars, etc.)

For AFP/PNP Employee, Serial/Badge No.

FREQUENCY OF MEMBERSHIP SAVINGS (MS)

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

For DepEd Employee, Division Code-Station Code

Semi-Annually
Annually

ADDRESS AND CONTACT DETAILS

*PERMANENT HOME ADDRESS
Unit/Room No., Floor

Building Name

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

Street Name

Subdivision
PUROK RIVERSIDE

Barangay
OLINGAN

Municipality/City
DIPOLOG CITY

Province/State/Country(if abroad)

ZAMBOANGA DEL NORTE

7100

Cell Phone
0930

Unit/Room No., Floor

Building Name

Barangay

Municipality/City

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

Street Name

Subdivision
PUROK RIVERSIDE

DIPOLOG CITY

Province/State/Country(if abroad)

7488953

Business (Direct Line)

ZIP Code

Business (Trunk Line)

ZAMBOANGA DEL NORTE

Local

7100

*PREFERRED MAILING ADDRESS

Present Home Address

Home

ZIP Code

*PRESENT HOME ADDRESS

OLINGAN

(Indicate country code if abroad)

COUNTRY + AREA CODE TELEPHONE NUMBER

Email Address

Permanent Home Address

Employer/Business Address

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.

wilgin_balas@yahoo.com
(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

X FACTOR CONTRACTORS AND GENERAL SERVICES

Building Name

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

KHUZNS PLACE BACK BLDG

Street Name

Barangay

NORTHROAD

Province

*State/Country (If abroad)

7,280.00

Land-based (Pls. specify country of assignment)

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

ZIP Code

6014

CEBU

*OCCUPATION

*TYPE OF WORK (For OFWs only)

ESTANCIA

MANDAUE CITY

0.00

Total Mo. Income

Subdivision

Municipality/City

Allowances/Others

*EMPLOYER/BUSINESS ADDRESS
Unit/Room No., Floor

7,280.00

*EMPLOYMENT STATUS

MODELS, DEMONSTRATORS, AND

PRODUCT PROMOTERS

Permanent/Regular
Casual

Branch ____________

Head Office

*DATE EMPLOYED (Month, Year)

Contractual
Project-based

Part-time/Temporary

April 2015

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

BALAS
BALAS

BALAS

FIRST NAME

WILSON
GINA

NAME
EXTENSION

MIDDLE NAME

NO MIDDLE NAME
(Check only if applicable)

RELATIONSHIP

FATHER

MALIN

MOTHER

DAMILES

SON

MAC DYNNIEL

DATE OF BIRTH

1 2

0 3

9 7 2

0 1

2 0

9 7 5

0 7

0 8

0 1 2

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

_________________________________

02/16/2016

_________________

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.