Kapisanan ng mga Katutubong Mamamayan

ng Maharlika, Incorporated (KKMMI) Passport

#099 Centro Street, Guyong, Santa Maria, Bulacan, Philippines size
ID
SEC Registration Number NR 201 903 111 0423 789 371 003
picture
Republic Act 8371 – Indigenous People’s Rights Act of 1997
Pursuant to Article 1-48 of the United Nations Declaration of the Rights of Indigenous Peoples

PERSONAL INFORMATION
Surname: Address: House/Lot Number

Given Name: Street

Middle Name: Barangay/Subdivision

Extension Name: City/Municipality

Marital Status: Province

___ Single ___ Married ___ Widow/Widower
Date of Birth (dd-mm-yyyy) Zip Code

Sex: Country
____ Male ____ Female)
SSS/GSIS Number Mobile Number

TIN Social Network Account

Spouse: Given Name Middle Name Surname, Extension Name Date of Birth (dd-mm-yyyy)

Children: Given Name Middle Name Surname, Extension Name Date of Birth (dd-mm-yyyy)

2. Date of Birth (dd-mm-yyyy)

3. Date of Birth (dd-mm-yyyy)

4. Date of Birth (dd-mm-yyyy)

5. Date of Birth (dd-mm-yyyy)

EDUCATIONAL BACKGROUND
Level School/Address Highest Attainment or Year completed if
graduate
Primary

Secondary

Tech-Voc

Bachelor

Graduate

Employment Background
Position Company / Address Inclusive Dates (dd-mm-yyyy)

Person to contact in case of emergency: Contact Number: Left thumb mark: Right thumb mark:

Signature of Applicant: Date Accomplished (dd-mm-yyyy)

Processed by: ID Number

Dear KKMMI Member,

Inasmuch as we value your trust and confidence in us, we would like to ensure that
KKMMI remains a trustworthy partner in your journey towards life prosperity, we are
making every effort to comply fully with the existing laws and regulations that govern
us.

In compliance with RA-10173 also known as the Philippine Data Privacy Act (DPA) of
2012, whose Implementing Rules and Regulations took effect on September 9, 2016,
KKMMI seeks to secure your consent on the general use and sharing of information
obtained from you so as to render certain services that collect, store, process, update,
share and disclose such information in relation to the KKMMI vision and mission.

Should you have questions or concerns about data privacy consent form, please send
your query to #099 Centro Street, Guyong, Sta. Maria, Bulacan, Philippines or contact
any of our KKMMI officers deployed in your area.

Sincerely yours,

KKMMI

DATA PRIVACY CONSENT

In compliance with the Data Privacy Act (DPA) of 2012, and its Implementing Rules
and Regulations (IRR) effective since September 8, 2016, I agree and authorize
KKMMI to:

1. Continue to use, process and update my information to administer the

benefits I am due as bona fide member of KKMMI.
2. Store and retain my information for such period coterminous with my
membership with KKMMI or until such time that I submit to KKMMI a written
cancellation of this consent, whichever is earlier. I agree that my information
will be deleted/destroyed after this period.
3. Share and/or disclose my information to KKMMI affiliates and to necessary
third parties for any legitimate purposes. I am assured that KKMMI employs
security systems that protect my information.
4. Inform me of future KKMMI plans and benefits and base its offer using the
personal information I shared with it.

I hereby certify that all information contained in this application are correct and
complete. I authorize you to obtain such information as KKMMI may require concerning
the statements made in this application and that the sources to which to which you
may apply for such information are hereby authorized to provide you the same. I agree
that the application may remain a KKMMI property whether or not the application is
approved. I also do hereby waive the confidentiality of all my information and further
authorize KKMMI to conduct random verification of such information.

I also acknowledge and warrant that I have acquired the consent from all parties
relevant to this consent and hold free and harmless and indemnify KKMMI from any
complaint, suit, or damages which any party may file or claim in relation to my consent.

Signed this _____day of __________________20___ at

_____________________________.

________________________
Signature over Printed Name

Should you have questions or concerns about data privacy consent form, please send
your query to #099 Centro Street, Guyong, Sta. Maria, Bulacan, Philippines or contact
any of our KKMMI officers deployed in your area.