DATE : July 1, 2020

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

FROM : Board of Directors

Data Privacy Officer

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

The PICPA Board of Directors and the newly appointed Data Privacy Officer wish to inform all members of
the Philippine Institute of Certified Public Accountants, Inc. (PICPA) that we are now updating our
members data base and in this regard we wish to get your written consent on the below listed concerns
below relative to the Republic Act 10173-2012 (Data Privacy Act), 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:

LOPE L. BATO, JR.

FY 2020-2021 National President

CONFORME:

Signature over Printed Name

PICPA Member

Note: Please send back to PICPA National Office, 700 Shaw Blvd., Mandaluyong City
or scan and email to membership@picpa.com.ph
 Philippine Institute of Certified Public Accountants
PICPA Building, 700 Shaw Blvd., Mandaluyong City
Tel.Nos. 723-0691 to 93 Fax Nos. 723-6305 / 726-9452 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

Tel. Fax
Position:
No.: 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.