PhilSys Form No.

1 THIS FORM IS NOT FOR SALE

REPUBLIC OF THE PHILIPPINES

PHILIPPINE STATISTICS AUTHORITY
PhilSys Registration Form
Please read the instructions at the back before filling out this form. Print all information in CAPITAL and in printed letters only. Place an (X) mark on applicable items
1 NAME D V
THIS INFORMATION WILL BE PRINTED ON PHILID CARD

(FIRST NAME) (MIDDLE NAME) (LAST NAME) (SUFFIX)

2 DATE OF BIRTH D V 3 PLACE OF BIRTH

- -
Y Y Y Y M M D D (City/Municipality) (Province) (Country for Resident Alien)
4 SEX D V 5 BLOOD TYPE D V 6 FILIPINO OR RESIDENT ALIEN D V
M
AL FEMALE Type:
FILIPINO RESIDENT ALIEN
E UNKNOWN
7 MARITAL STATUS (OPTIONAL) D V

SINGLE MARRIED WIDOWED DIVORCED LEGALLY SEPARATED ANNULED NULLIFIED

8 PERMANENT ADDRESS D V

(Rm/Flr/Unit No. Bldg. Name) (House/Lot/Block No.) (Street) (Subdivision) (Barangay) (City/Municipality) (Province) (Co
PRESENT ADDRESS (OPTIONAL) D V

(Rm/Flr/Unit No. Bldg. Name) (House/Lot/Block No.) (Street) (Subdivision) (Barangay) (City/Municipality) (Province) (C
9 MOBILE NUMBER (OPTIONAL) 10 EMAIL ADDRESS (OPTIONAL)

PhilSys notification will be sent through the provided Mobile Number Only PhilSys notification will be sent through the provided Email Address Only
11 DETAILS OF MOTHER/FATHER OR GUARDIAN (FOR CHILDREN BELOW 5 YEARS OLD)

MOTHER: PSN

- - -
(FIRST NAME) (MIDDLE NAME) (LAST NAME) (SUFFIX)
FOR PROCESSING PURPOSES ONLY

FATHER OR GUARDIAN: PSN

- - -
(FIRST NAME) (MIDDLE NAME) (LAST NAME) (SUFFIX)
12 REGISTRATION TYPE
DOCUMENT-BASED (Indicate the document/s presented as listed at the back of the Form) (For resident alien)
SUPPORTING DOCUMENT/S PRESENTED BReN/ID Number/ACR I-Card Number (For resident alien) Length of stay (No. of days)
1
2
INTRODUCER-BASED
QUALIFIED INTRODUCER'S FULL NAME: QUALIFIED INTRODUCER'S PSN

- - -
(FIRST NAME) (MIDDLE NAME) (LAST NAME) (SUFFIX)

I hereby confirm the identify and demographic information of as being true, correct, and accurate.

QUALIFIED INTRODUCER'S SIGNATURE OVER PRINTED NAME DATE

13 MODE OF CLAIMING THE PHILID CARD

PICK-UP DELIVERY TO PERMANENT ADDRESS DELIVERY TO PRESENT ADDRESS

DISCLOSURE UNDER SECTION 12 OF DATA PRIVACY ACT OF 2012 (RA No. 10173):
I hereby declare that I am fully aware that the above data shall be used for securing PhilSys Number (PSN) for the Philippine Identification System,
issuance of PhilID, authentication or updating my demographic and biometrict information in the PhilSys Registry. I trust that the above information shall
remain confidential, hence, I give my consent that the same data be accessed for subsequent validation, verification, and other purposes consistent with
the objectives of the PSA under RA No. 11055. I further affirm that all statements/information which appears in this registration form and made by me,
are true, correct, and complete to the best of my knowledge and belief.
 APPLICANT'S SIGNATURE OVER PRINTED NAME

LEFT THUMB RIGHT THUMB

DATE (If the Applicant cannot sign, affix fingerprints in the presence of the Screener/Encoder)
FOR THE USE OF THE PHILIPPINE STATISTICS AUTHORITY ONLY. PLEASE DO NOT WRITE BELOW THIS LINE
SCREENER ENCODER BIOMETRICT EXCEPTIONS
(To be filled out by Supervisor)
FRONT FACING PHOTOGRAPH IRIS SCAN
FULL SET OF FINGERPRINTS

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME DATE