Contact Nos. (2) 8822-MBAI (6224) Website: wiv afpmbal com ph [ARMED FORCES AND POLICE MUTUAL BENEFIT ASSOCIATION, INC. (Col Benny Serano Road cor E, Delos Santos Avenue, Camp Aguinldo, Quezon City BAL Email: mal@afpmbsiph Facebook @AFPMBAIOficial | eco [JFoRr MBAI ID CARD ISSUANCE [For upparine onty MBALID NO. : ‘CARD/ACCT NO. PLEASE PRINT ALL CAPS vasrname: |__|} ttt ttt ttt tt i_i_ PRSTNAME: |__| __|__1__1_—1— tI 1111 ttt tt ie i_ Mioole NAME: |____}__ tt} tt tt ttt ie RANK: SERIAL/ACCT NO. BRANCH OF SERVICE. oTHERs UNITASSIGNMENT: |__|} 1111} ttt tii uniraooress: |__|} J ttt tt tii SERVICE STATUS DATE OF isctve /ebre/Diserared /Separatee) PAY JURISDICTION (Retwement/Dicarge /Sepraton] DATE ENTERED SERVICE RANK AS OF ENTRY J) J RANK AS OF SEPT 1985 RANKASOF SEPT1982 ATE OF LAST RANK AS OF LAST (for AFP) tforPNP) PROMOTION/DEMOTION _ PROMOTION/DEMOTION ATE OF BIRTH i eee ee LACE OF BIRTH Ace enoeriwe) cuustarus—™Waionaury GSISNO, PhiISyS NO-(PSN) /UMIONO.__PHILHEAUTH NO. TAX IDENTIFICATION NO. (mens) wigs” TYPE” MOBILE NO. 2 HOME PHONE No. EMAIL ADDRESS PRESENT ADDRESS: |_| _|_{__{__|__|__J__J__1__1__1_1_1_1_1_1_1_1_| Room No: /Oice Name, dg. House Wo, Street, SuBa-/ Barangay iat / Town / Sy Provce [County Zipcode PERMANENT ADDRESS: |__| _|__|_|____|__|__|__}__J__1__1__1__!_!_1!_1 oom No. 7Otiee Name, dg. / Wouke io, Sree, Suba, Barangay Diaret / Town / Cy Provce [Country Zipcode NATURE OF EMPLOYMENT/BUSINESS: NATURE OF EMPLOYER/BUSINESS NAME: SOURCE OF FUNDS (Jsatary / Pension [ton proceeos [olusiwess [sate oF proreaty Clinnierirance lotaers (speciey): DO NOT FILL OUT (For AFPMBAI use only) FOR MBAI ID CARD ISSUANCE EFTTHUMEMARK HT THUMBMARE TYPE OF ISSUANCE TYPE OF MEMBERSHIP IDs Presented w/ photocopies (new (recur (service 1 / Company 1D [reissue [5 associate (J covernment issued ID Passport PROCESSED BY: [APPROVED BY. RECEIVED By: Se oe TS SR TS Tama oo TION Ta AT RATT “As of Rugust 2020MOTHER'S MAIDEN NAME (U0NG PANGALAN NGINA NOONG OALAGA) ‘CONTACT PERSON IN CASE OF EMERGENCY: NAME RELATIONSHIP. CONTACT NO. ‘ADDRESS BENEFICIARIES FOR BASIC INSURANCE/SGTI "NAME OF DEPENDENT NAME OF DEFENDENT. 7 yd DATEOF BIRTH cenoentw/r) RHATIONSHPW7NSURED_DATEOF BIRTH ‘GENDER (M/A) RELATIONSHIP W7 INSURED TAME OF DEPENDENTS NAME OF DEPENDENT 77 a) DATE OF BIRTH ENDER) RELATIONSHIP WIINSURED—DATEOF RTH ‘GENDER w/A) RELATIONSHIP W/NSURED Do/mm/vrvr Bolmmrvne NAME OF DEPENDENTS NAME OF DEPENDENT rot a) DATE OF BIRTH GENDER) RELATIONSHIP W/INSURED—_DATEOF SIRT (GENDERIM/A) RELATIONSHIP W/ INSURED TAME OF DEPENDENT TAMEOF DEPENDENTS 77 77 DATE OF BIRTH cenoen(w/r) RIATIONSHPW/INSUREDDATEOF BIRTH GENDER M/A) RELATIONSHIP W/NSURED bo/mm/yrvr Soyumrveve Iuore: eas ross otf succeeding numberof benefice ore rot needed Pursuant to Republic Act No. 9510 creating the Credit Information Corporation (CIC), its Implementing Rules and Regulations (IRR), and various Circulars, the AFPMBAI is mandated to submit the borrower's basic credit data as defined by law, as well as any regular updates or corrections thereof, to the CIC for consolidation and disclosure as may be authorized by the CIC. Consequently, the basic credit data may be shared with other lenders and other credit reporting agencies duly authorized by the CIC, for the purpose of establishing the borrower's creditworthiness. For more information, please visit the website at www.creditinfo. gov-ph, AFPMBAI upholds an individual's data privacy rights and observes that all personal information, sensitive personal information and privileged information collected and to be collected are processed or recorded, managed, organized, stored, updated, retrieved, consolidated, used, blocked, and erased according to the Data Privacy Act of 2012 (RA 10173), its Implementing Rules and Regulations (IRR), and various Circulars under the principles of transparency, legitimate purpose, and proportionality, | hereby give my consent to the processing, sharing, and/or transferring of my personal data relating to my account/s, without notice, to AFPMBAY, its service providers and entities or third parties having authority or right to such disclosure of information as in the case of regulatory agencies, governmental or otherwise, which have required such disclosure from AFPMBA\, also to enable AFPMBAI to service my account/s, to provide al exiting features and future enhancements thereto, and to aval other AFPMBAI products, services, facilities and channels as the AFPMBAI deems necessary. | agree to hold AFPMBA, its afliates, subsidiaries and third party service providers free and harmless from any liability arising from or in connection with the consent herein given. ‘Signature over printed name “As of Rugust 2020