“e. SCOataFo NCSC “eScostaform NCSC “eScOstaform NCSC Residence (House Tat tee uel) 2. Adddrass (Select region fst, then province, No./Block/Lot/Zone/Purok/Sitio) * ctyand tly baragey) 1, Name (Type your name correctly as Region * required below. Younamewillbeused io | Selact Region ¥ sired below. ibe used att authenticate your applicetionm for 3 registration) — Lastname (apetyido) * Gpeiyido) 3. Birth Date. city* v Seas aeatoarcrsinann asa Firstname (Pangalan)* Sineooe cyano, Barangay * sey Month * Middlename-Gitnang Pangalan - Date* Residence (House No./Block/Lot/Zone/Purok/Sitio) * a Extension (Jr/sr-/i/i/i.) Year* a @ ® 2. Address (Soloctregion first. nD © cick to vaidate your birthday i ° < i“e.SCDataFerm [NCSC “eSCOataFerm CSC “eSCOataFerm CSC ee ena 10. Ethnic Origin 16.SC Association ID No. 5. Marital Status* ‘1. Language Spoken 17.Other Gov't ID No. 12.OSCAIDNo. 7.Gender* 18. Employment / Business 13.GSIS/SSS No. 8. Contact Number* 19. Current Pension 14.71N 9a, Email Address * 20. Capability to Travel 15.PhilHealth No. 9b. Messenger Name aCe eo 10. Ethnic Origin cron‘e$cOaaForm NCSC ‘e$cOataForm NCSC ‘e$cOataForm NCSC dere A deebeeddeed SaieIeseeeienene jastname, 25. Living Condition (Check all 21. Name of your spouse ares Lastname Firstname © ting alone © Living with Firstname Midalename | Grena chitdren common Law Spouse Ospouse Middlename Extension Siimtaws Care institution (Cochitdren eae Relatives: 23. Name of your mother © Friends (Others Lastname Spec 22. Name of your father Lastname Fieinems: 26. Housing Condition (Check all applicable) (No privacy | Overcrowded in home < uM ° < u ° <“e.SCDataFerm [NCSC “e.SCDataFerm [NCSC “e.SCDataFerm | NCSC 24, Name of your children (Enumerate the first five and arrange them from ‘oldest to youngest) Complete Name Occupation a 24.a Other Dependents Income Age Is Working?“eSCOataFerm CSC “eSCOataFerm CSC Lari ta 32.4 Assets: Real and immovable Properties (Check al applicable) “eSCOataFerm CSC 30. Involvement in Community ‘Actives (Check all applicable) 531. Source of Income and Assistance House Cece (Check all applicable) ere |_| Resource Volunteer Own earnings, salary / wages: _|House & Lot [Cleon Beeuttoason ~ Own Pension ~ Commercial Bung [leant reer stocks / Dividends ~ Fiehpond /resort Cera ~ Dependent on chisron /rlatves [Friendly Visits _|Spouse's salary |__| Nelghbornood support Services _|Spouse Pension mo ~nerance 32.8 Assets: Personal and Movable (C Retiious Rental Sharecorp Properties |_| Counseling / Referral __|Sevings Automobile sponsor | bvestock orchard arm Personal Computor aaa Fishing = Boats sane Hae Eaipment mee [Drones Sool ol oda ola 32.4 Assets: Real and Immovable ___ Motoreycle Properties (Check all applicable) Mobile Phones 31. Source of Income and Assist ed (Check all applicable) [Lot Farmland a House & Lot < uN ° < u“e. SCDataFerm | NCSC “eSCOataFerm CSC 33. Monthly Income (in Phitiopine Peso) thers, Saiy © 60000.and above CIRC aoe O 50000 to 60000 Eo 35.A Medical Concern 35.8 Dental Concern O 30000 te 40000 “eSCOataFerm CSC | Noes Dental Care Blood Type* © 20000 to 30000 ae = Others, Specty © 10000020000 © 5000 t010000 Phyetcal Denby * 35.C Optal © below 5000 Phyl Diaby pe hare Caer © Noods ae cae 34. Problems / Needs Commonly Encountered (Check all applicable) Health Problems / Ailments Others. Sect [Lack of income / resources _ Hypertension [Coss of income / resources, Pisa bead _ 35. Aural Stas /capabily tring (spec UE oO Sey Ciovabeiee Aral impatment Lvethood Chronic Kidney Disease Others, Sect Atheimers / Dementia thers Specty | Chronic Obstructive PumonaryDis088° 936, Social / Emotional = Se [ret alt rten | Feeling helplessness /worhloson < "‘e$cOataForm NCSC “eSCDataFerm NCSC “e. SCDataFerm | NCSC 35.D Aural 36.List of Medicines for Maintenance 3-19. Pao) (Type all your maintenance medicines eae lla he below. Example : Amlodiphne 1omg, Losartan 50mg, etc) Aral ipaient ‘Others Spec 35.£ Social / Emotional [ATTACH IMAGE OF YOUR OSCA*ID bi * Offic of Serie Cizen tsrs(OSCA) Fooling neglect rejection Pena take on imoge o picture of your OSCAID ( Feoing helpless / worblsenes ry govern bt ach tre To [Ceeting tonainess /toite suschte ape eof yur OSC ( Lackletsure recreational aces 37.Do you have a scheduled Heiney aafuashed-astaueemhareae erent | Lack $0 tendly envionment medical/physical check-up? mobi Others, Specty a oO 37,A\If Yes, whenis it done? Oo 35.F Area / Difficulty ¥ poe [High Cost of medicines | Lack medicines | Lack of medical attention OSCAIDAND PHOTO + Click here to select an image ATTACHMENT (thers, Spec Image must not exceed “2se ¢ostaferm| Nese ATTACH YOUR ACTUAL PHOTO. To attach your captured phot, take your setul picture © selfie using your mabile phone and ‘lek onthe Upload button below and locate the photo file rom your device to unio there. We need a cloze-up image of your face, 20 pase take 3212 size photo capture ony. CTA) a) See ona Tracy Image must not exceed 5OMB se ¢ostaferm| Nese Daa Create your own Pass Key Number (PKN) below, Youwinang ts to access and verify your recordlater The maximum combination for the nominated PRN four (8) ison Enter RN Re-enter PRN iste ian uta ae no < se ¢ostaferm| Nese ec eDer Ls a Please affix your signature (ithe applicant i not able to sign just proceed ‘and leave te signature blank) ‘ange desktop compte laptop use your mouse to tian by porting tothe space bolo letctek and Seicn use your ingertp to sew your signet. You ‘an change you signature by clcking on the ‘ea PLEASE SIGN IN THE SPACE BE Low +“e. SCDataFerm [NCSC “e. SCDataFerm [NCSC “e. SCDataFerm [NCSC Assisted by Pre UR eR tC Naar seen oe pineriptivaneeebire ten BEFORE YOU SUBMIT Iadeton oftheregewee Conc, Malm ara So review at ormalan Ne chee le et i This is to certify that cick the ‘Submit’ button below. Once the Actes bases os ents be ‘The information entered above is true: 2 ee ee a ae ee O aisecne sting naceaney afar aaron IMPORTANT : READ THIS hasbeen completed, you hove to wite 2 Cr Hsgiteutinanacoehmorisne BERT VOU SUBRATT [ater ofntent forthe medication of our ine i 0 ‘ousu record. Again, please be reminded that You ony have to register once, We can Vandi agape teceing Malm ou fovea tat ren C1 pyreintermeaiyettehom ——ehave rovtedin tis frm before you SHY caGH any cnt region click the ‘Submit’ button below. Once the ee ipmaal geaigy pcg chan eesti fer bt thle eat it fom your end. When ao fern for adminstrtive purposes of pete ce oie yarenbiiade ‘entries are complete and correct, click the has been completed, you have to write @ "Submit" button Below to proceed. understand thatthis form contains my ett of intent for the modification of your 1 personal information tobe stored in the (CSC senor chtzeradatabese: record. Again please be reminded that -check muna lahat_ng_pangalan, you only have to register once. Wecon address, birthday, at iba pang cor tr at ng easily catch any dupicate reais idee Bios rab Mati 1 Berson whose name is ndicated eee ‘may mali sa naisubmit mo, kal i that such person's personsly sumulat_sa_phnesc@gmailcom at " < " <