TO : All Members, Philippine Institute of Certified Public Accountants, Inc.

FROM : Board of Directors

Data Privacy Officer

DATE : July 11, 2018

SUBJECT: Membership Date Base (in relation to Data Privacy Act of 2012)

The BOD and the newly appointed DPO has the honor to inform the general membership that the
Philippine Institute of Certified Public Accountants, Inc. (PICPA) National Office is updating its members
data base and in this regard we want your written consent on the below listed concerns, to wit:

1. Give consent to PICPA to communicate with each member through emails, mobile and landline
phones.
Yes No
Comment

2. To allow PICPA to make, and issue member’s identification card containing their name,
picture, PRC ID No. and sectoral information
Yes No
Comment

3. To allow PICPA and its authorized IT provider, to process and include in the member’s
database the necessary information of member.
Yes No
Comment

To maintain privacy of each member, the PICPA and the IT officer-in-charge will issue a
“Non-Disclosure Agreement”.

Attached is the Form which contain the information which you are allowing PICPA to be included
in the members’ database.

For the Board of Directors:

MA. ASUNCION GOLEZ

President

CONFORME:

Signature over Printed Name

PICPA Member
 Philippine Institute of Certified Public Accountants
PICPA Building, 700 Shaw Blvd., Mandaluyong City
Tel.Nos. 723-0691 to 93 Email: membership@picpa.com.ph

MEMBERS UPDATE FORM

*CPA/PRC Reg.No.: *PRC Reg. Date: PRC Expiration Date:
MM DD YYYY MM DD YYYY
Name :
* Surname * First Name * Middle Name * Mother’s Maiden Surname

* Birthday: Sex: Female Civil Status: Single Widow

MM DD YYYY Male Married Separated
Other:

WORK INFORMATION
Company: Industry:
Company Address:
Floor/Unit/Building Street No. Street Name(s)

Barrio/Barangay/Subdivision Municipality / City / Province Zip Code

Position: Tel. No.: Fax No.:

Cel No.: Email:

HOME INFORMATION
Home Address:
Floor/Unit/Building Street No. Street Name(s)

Barrio/Barangay/Subdivision Municipality / City / Province Zip Code

Cel No.: Tel. No.:

Fax No.: Email:

Preferred Mailing Address: Office Home Address

Membership Affiliation:
Region: Sector: Commerce & Industry Government
Chapter: Education Public Practice

Type of Member:
Regular Sustaining Life Member (SLM) Honorary Life Member (HLM)

I HEREBY CERTIFY that the above information are true and correct to the best of my personal knowledge and belief. I further certify that the
above information were given as my voluntary act and deed. Furthermore I am giving PICPA my full consent to include the above information in the PICPA
member’s database and to update the same from time to time without further asking my written consent.

The above data includes sensitive

personal information that need written
consent of the data subject, under the Data
Privacy Act of 2012.
2 x 2 picture
INFORMATION
(for verification purposes)
For inquiries, please call (02) 723-0691 to 93

Place your SIGNATURE inside the box. Make sure it will not touch the sides of the box.

TIN VAT NON-VAT