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NATIONAL COMMISSION OF SENIOR CITIZENS

ONLINE SENIOR CITIZEN

DATA FORM

New Application
Please fill up completely and correctly the required
information before each item below. For items that are not
associated to you, leave it blank. Required items are also
marked with an asterisk (*) so please fill it up correctly. Your
honest response will help the National Commission of
Senior Citizens (NCSC) come up with a good information
system of the senior citizens in the country as the basis of
designing its programs and activities that will help improve
the lives of Filipino older persons.

* Items with an asterisk (*) are required.

I. IDENTIFYING INFORMATION

1. Name - Enter your name correctly

Lastname (Apelyido) *

Navarro

Firstname (Pangalan) *

Rosalinda

Middlename (Gitnang Pangalan) *

Ocaña

Extension
I have name extension

2. Address - Select region first, and then

province, then city, and finally your barangay

Region *

REGION IV-A

Province *

CAVITE

City *

GENERAL TRIAS

Barangay *

MANGGAHAN

...

Residence (House No./Block/Lot) *

216 bagong pook

Street (Zone/Purok/Sitio) - Not required

Manggahan general trias cavite

3. Birth Date - Indicate your birth date

correctly

Month *

May

Date *

22

Year *

1951

Click here to check for your age.

4. Birth Place

5. Marital Status *

6. Religion

7. Sex at Birth *

8. Contact Number *

9a. Email Address - (Put NONE if there is

no email) *

9b. FB Messenger Name

10. Ethnic Origin

11. Language Spoken

12. OSCA ID No.

13. GSIS/SSS No.

14. TIN

15. PhilHealth No.

16. SC Association ID No.

17. Other Gov't ID No.

18. Employment / Business

19. Current Pension

20. Capability to Travel

II. FAMILY COMPOSITION

21. Name of your spouse

Lastname

Firstname

Middlename

Name Extension

22. Name of your father

Lastname

Firstname

Middlename

Name Extension

23. Name of your mother

Lastname

Firstname

Middlename

Name Extension

24. Name of your child(ren) - If

applicable, enumerate the first five and
arrange them from oldest to youngest

Complete Name

1. Child Name

Occupation

Occupation

Income (Optional)

Income

Age Is Working?

Age Is working?

2. Child Name

Occupation

Income

Age Is Working?

3. Child Name

Occupaton

Income

Age is Working?

4. Child Name

Occupation

Income

Age Is Working?

5. Child Name

Occupation

Income

Age Is Working?

24.a Other Dependents - If applicable,

specify your dependents below.
Dependents are those living with you

1. Name of Dependent

Occuption of Dependent

Income

Age Is Working?

2. Name of Dependent

Occupation of Dependent

Income

Age Is Working?

III. DEPENDENCY PROFILE

25. Living Condition (Check all applicable)

Living Alone

Living with

Grand Children

Common Law Spouse

Spouse

In-laws

Care Institution

Children

Relatives

Friends

Others

Specify

26. Living Condition (Check all

applicable)

No privacy

Overcrowded in home

Informal Settler

No permanent house

High cost of rent

Longing for independent living

quiet atmosphere

Others

Others, Specify

IV. EDUCATION / HR PROFILE

27. Highest Educational

Attainment

Not Attended School

Elementary Level

Elementary Graduate

Highschool Level

Highschool Graduate

Vocational

College Level

College Graduate

Post Graduate

Others, Specify

28. Specialization / Technical Skills

(Check all applicable)

Medical
Dental
Fishing
Engineering
Barber
Evangelization
Millwright
Teaching
Counselling
Cooking
Carpenter
Mason
Tailor
Legal Services
Farming
Arts
Plumber
Shoemaker
Chef/Cook
Information Technology

Others, Specify

29. Shared Skills (Community Service)

Type skills here separated by comma

30. Involvement in Community

Activities (Check all applicable)

Medical

Resource Volunteer

Community Beautification

Community / Organization
Leader

Dental

Friendly Visits

Neighborhood Support Services

Legal Services

Religious

Counselling / Referral

Sponsorship

Others, Specify

V. ECONOMIC PROFILE

31. Source of Income and Assistance

(Check all applicable)

Own earnings, salary / wages

Own Pension
Stocks / Dividends
Dependent on children / relatives
Spouse's salary
Spouse Pension
Insurance
Rental / Sharecorp
Savings
Livestock / orchard / farm
Fishing

Others, Specify

32.A Assets: Real and Immovable

Properties (Check all applicable)

House
Lot / Farmland
House & Lot
Commercial Building
Fishpond / resort

Others, Specify

32.B Assets: Personal and Movable

Properties

Automobile
Personal Computer
Boats
Heavy Equipment
Laptops
Drones
Motorcycle
Mobile Phones

Others, Specify

33. Monthly Income (in Philippine Peso)

This item is optional

60000 and above

50000 to 60000
400000 to 50000
30000 to 40000
20000 to 30000
10000 to 20000
5000 to 10000
below 5000
None

34. Problems / Needs Commonly

Encountered (Check all applicable)

Lack of income / resources

Loss of income / resources

Skills / capability training

(specify)

Livelihood Opportunties (Specify)

Others, Specify

VI. HEALTH PROFILE

35.a Medical Concern

Blood Type *

Physical Disability

Physical Disability type here

Health Problems / Ailments

Hypertension

Arthritis / Gout

Coronary Heart Disease

Diabetes

Chronic Kidney Disease

Alzheimer's / Dementia

Chronic Obstructive Pulmonary

Disease

Others, Specify

35.b Dental Concern

Needs Dental
Care

Others, Specify

35.c Visual Concern

Eye impairment

Needs eye care

Others, Specify

35.d Aural/Hearing Condition

Aural impairment

Others, Specify

35.e Social / Emotional

Feeling neglect / rejection

Feeling helplessness / worthlessness

Feeling loneliness / isolate

Lack leisure / recreational activities

Lack SC friendly environment

Others, Specify

35.f Area of Difficulty

High Cost of medicines

Lack of medicines

Lack of medical attention

Others, Specify

36. List of Medicines for Maintenance

(Type all your maintenance medicines.
Example : Amlodiphne 10mg, Losartan
50mg, etc.)

37. Do you have a scheduled

medical/physical check-up?

37.A If Yes, when is it done?

OSCA ID AND PHOTO

ATTACHMENT

ATTACH IMAGE OF YOUR OSCA* ID

* Office of Senior Citizens Affairs (OSCA)

Please take an image or picture of your

OSCA-ID or any government ID and attach
it here. To attach the image file, take a picture of
your OSCA ID and then click on the "Upload your
ID" button to locate the image file from your local
drive or mobile.

If you don't have an OSCA ID then you

can attach any valid ID you have in your
possesion.

Upload/take photo of your ID

Image must not exceed 50MB

ATTACH YOUR ACTUAL PHOTO

To attach your captured photo, take your actual
picture or selfie using your mobile phone and
click on the Upload button below and locate the
photo file from your device to upload it here. We
need a close-up image of your face, so please
take a 2x2 size photo capture only.

Please take a selfie of your face. Do not

attach a whole-body picture or your
younger-year photo, we need the actual
senior photo of your face only.

Upload/Take Photo

Image must not exceed 50MB

 PASS KEY NUMBER

Create your own Pass Key

Number * (PKN)
Please create your own PKN for your registration
below. You will need this to access and verify
your record later. The maximum combination for
the nominated PKN is four (4) digits only.

Enter PKN
Type here...

Re-enter PKN
Re-type here ...

Warning : Make sure to remember and

take note of your PKN before
submitting.

CONFIRMATION TO ALLOW
THE STORAGE AND USE OF MY
PERSONAL DATA

This is to certify
that
The information entered above is true
and correct.

I have the full knowledge in providing the

above information.

I understand the purpose of enrolling

myself in the registry of the National
Commission of Senior Citizens.

I have personally given my consent to

allow the use of the information
contained in this form.

I understand that this form contains my

personal information to be stored in the
NCSC senior citizens database.

I have certified further that during the

filling-out of this form, I was assisted by
the person whose name is indicated
below and that such person is personally
known to me.

Assisted by
Type here the complete name of the …

Relation to the registrant /

Contact No.
Type the relation here

Proceed to Submit

Cancel

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