CE Se suet REPUBLIC OF THE PHILIPPINES y PHILIPPINE STATISTICS AUTHORITY 4 PhilSys Registration Form 1A L@ Se" FOR 5 YEARS OLD AND ABOVE Ks4 Please read the instructions at the back before filling out this form. Print all information in CAPITAL letters and use BLACK ink only. Place an "X" mark on the applicable items. TRIDDLE NAWET TSE EE 3 [DATE OF BIRTH Cremate PLACE OF BIRTH CCAETAETATTT TPOMNeE) 6 |FILIPINO OR RESIDENT ALIEN Tye CUUNKNOWN OD Furino Co RESIDENT ALIEN 7 | MARITAL STATUS (OPTIONAL) since = COMARRIED Cwioweo Doivorceo = CLEGALLY SEPARATED Dlannuueo ——_ Chnuuwirieo [A. PERMANENT ADDRESS THROM WO GLO RANE TOUS TOTOCRNOT Te TEST EARANGAY RCPAI FROME] oo IB. PRESENT ADDRESS (OPTIONAL) TISAME AS PERMANENT ADDRESS a EURVUNTT WO. BLDG NAME ERENGAT MOBILE NUMBER (OPTIONAL) [SUPPORTING DOCUMENT/S PRESENTED (indicote the d ented as listed at the back of the Form.) TYPE OF DOCUMENTS. BReN/ID NumberJACR I-card Number OO | 12 | MODE OF PHILID DELIVERY CIDELIVER TO PERMANENT ADDRESS CIDELIVER TO PRESENT ADDRESS DISCLOSURE UNDER SECTION 12 OF DATA PRIVACY ACT OF 2012 (RA No. 10173) |: hereby declare that | am fully aware that the above data shall be used for securing a Philsys Number (PSN) under the lPhitippine Identification System, Issuance of PhillD, authentication and/or updating my demographic and biometric information lin the Philsys Registry. | trust that the above information shall remain confidential, hence, | give my consent that the same data lve accessed for subsequent validation, verification, and other purposes consistent with the objectives of the PSA under RA No. |12055. 1 further affirm that all statements/information appearing in this registration form are made by me, true, correct, and Jcomplete to the best of my knowledge and belief. (FOR the Applicant who CANNOT SIGN, AFFIX fingerprints in the presence of a PhlSys Registration Personnel.) ~~ APPLICANT'S SIGNATURE OVER PRINTED NAME (Must be signed in the presence ofa PhiSys Registration Personnel) DATE TERT THUMB RIGHT THUMB (OF THE PHILIPI LE ELOW THIS LINE. FOR TIFRONT FACING PHOTOGRAPH: CInSSCaN irineeapaints Deft irs, Speci Diaiht irs TENTED SEAT ETON SEAT OA EOE SEOINSTRUCTIONS ‘A THIS FORM IS TO BE FILLED OUT WITH INFORMATION OF THE APPLICANT AGES FIVE (6) YEARS OLD AND ABOVE 8B FILLOUT THIS FORM IN ONE (1} COPY. AVOID ERASURES AND ALTERATIONS. LINE OUT OR STRIKE THROUGH ANY [ERRONEQUS ENTRY ONCE AND PUT YOUR INITIALS ABOVE THE ERASURE PLACE AN "X" MARK ON THE APPLICABLE ITEMS. 1 FILLOUT THE APPROPRIATE ITEMS IN THE SPECIFIED FORMAT IP AREQUIRED FIELO IS NOT APPLICABLE, INDICATE "NIA" OR "NOT APPLICABLE” 41. NAME Indicate your Full Name staring fom your First Name, Mile Name, Last Name, and Suc Example: JUAN” SANTOS—-DELACRUZ JR (RST NAME) (MIDDLE NAME} (LAST NAME) (SUFFIX) 2.98% Place an X° mask onthe selected box Example: HALE CIFEMALE 3. DATE OF BIRTH Flin Oat of Bit in YYYY-MN-DO Example: 1983-08-10 (ryvvrnatoo) 4. PLAGE OF BIRTH For Fipino ciizen, naa the name of he CiyMunicpaly and Province of your Pace of Birth Exam SAN JUAN. METRO MANILA PHILIPPINES (Ciynricipaiy) (Province) (County) ForResient Alen, indeate the County of your Place of ith Leave the CiyMunicipalty blank Example: NA NA, Usa. (Chynhineieain) (Prownee) ——Caurty) 5. BL000 TYPE Indicate your Blood Type If unknown, put an "mark onthe box proved Ecsngi ype: AB “Bunevown 6. FILIPINO OR RESIDENT ALIEN Place an "X° mak onthe selected box f Figina or Resident Aen Example: FUiPINO OORESIDENT ALIEN 7. MARITAL STATUS (OPTIONAL) Place an°X markon the selected box xample: TBSINGLE QUARRIED [WIDOWED CoVORCED CLEGALLY SEPARATED Dannuiieo ONuLuFieD ‘Note: a married woman presenting 8 supporting document reflecting her maiden name but chooses fo use her maried name, she must (presenta PSA Issued Certieae of Marioge. B.A.PERMANENT ADDRESS incicate your complete aasess B. PRESENT ADDRESS (OPTIONAL) Example ‘A. PERMANENT ADDRESS a3 Block 143 ATS _MASAYA MALIGAYA QUEZONCCITY METRO MANILA PHILIPPINES (RrvFiiUnt No. Bldg Name) (House'LovBlock No) (Sree) (Subenvison) (Barangay) (CiyMuncipalty) (Province) (County) 1B. PRESENT ADDRESS (OPTIONAL) Bra Fir Lot 123 ARAW MASAGANA MAPAYAPA MAKATI METRO MANILA PHILIPPINES {RIVFI/UnK No. Bldg Name) (HOUSETLOVBIock No} (Sree) (SubANson) (Garangay) (CiyMuneseaity) —(Provnce) (County) For Resident Alien, indicate the Permanent Adress that you are sing in your country andthe Present Address her in the Philipines. Examale: 2, PERMANENT ADDRESS ‘ini 343 Lots APPLE CALIFORNIA USA (Rivlin No. Bide Name) (Heuse!LovBlock No} (Sree (Subkvison) (Barangay) (CiyMuncicaly) (Semncestate) (County) PRESENT ADDRESS (OPTIONAL, Sra ir Blocks IRIS PSA MAAYOS —_ANTIPOLORIZAL_ PHILIPPINES (RIVEFUnt No Bisa Name) (Housel ovBlock No) (Steet) (Subavsion) Barangay) (GiviMimasaity) — (Provnce) {County {8 MOBILE NUMBER (OPTIONAL) Incest your pimary Mobile Number in case the applicants amine, he Mabie Number cthe parent or guardian may be indicated ‘Example: MOBILE NUMBER (Optional) 061820881 Piss natiicabon ull be sent ough te proved mebie cumber only 10, EMAIL ADDRESS (OPTIONAL) Inceate your active Emal Address. Email adress is ot case sensitive and smal lets willbe accepted bythe screener ‘Example: EMAIL ADDRESS (Optional philsys@osa.gov.oh Piss noticaton ube sent ough te powded ema acress ony 11. SUPPORTING DOCUMENTS PRESENTED Virte te name of me supporting Socuments presented. Refer t these supporting documents blow [SRN/ID NumberiACR Cara Number ‘ite he BREN ID Number and ACR Lara Number Example SUPPORTING DOCUMENTIS PRESENTED | BReWID Number/ACR Lard Number 4. PSAiesues Cortieste of Live Birth BREN 123XXXXXXXXAX, etal ID No, 1289000000 12, MODE OF PHILIO DELIVERY CODELVER TO PERMANENT ADDRESS Puan "X'matk onthe bor you nant your PID cardio be delvre at your Pemanert Ades (CUDELVER TO PRESENT ADDRESS Putan mark on he Box you wan you PID cardio be delvated a yeu Present Adress. ‘SUPPORTING DOCUMENTS [The duly accomplished aplication form shall be supported by presenting an eriginal copy a ny ofthe following PRIMARY suppenting documents “ PSAissued Ceres of Lve Btn AND ene (1) aovernmentissuediderificaton document wh ful ame, phcto and signature or humbmare, 2. DFAissued Phipone Passport 5. G85 or 98Sissued Unites Mul. Purpose lentiicaton (UMD) Ca 4_LTOusved Student's Ucense Perm or Non-ProessinalProfessional Drivers License [Fie above-mentioned documents are not avsilsle, present an orignal copy of any of te following SECONDARY supporing dosumeris PSA eaued Cortfeate of Live Brtn/ NSO-esved Carats [Tz License to Ov or Possess Frame (LTOPF) five Birth wth Birth Reference Number (BREN) 18 Natonal Buteau of vestigation (NB!) Clearance 2 LGRO-ssved Cerficte of Live Birth 14 Poke Clearance 5 PsAissues Repar of Sch 18 S00 Parent D 44. PS iesues Certs of Pounding 16, Person With Disabilty PWD) 1D 5 Integrated Ba ofthe Phippnes (BP) 1D 47 Voters 6 Professional Regulation Commission (PRC) ID 18 PostaliD 7 Seaman Bose 19. Taxpayer ientiicaton Number (TIN) 1D 8. Overseas Workers Weifare Adminitaton (OWWA) 20. Phteath D (FW e-cardhDOLE OFWID 21, Phivgpine Ratverant Author (PRAY isu 9. Seni Cizen ideation Cord ‘Special Resident Retiree’ Vise (SRRV) 10: Social Securty Systm (S35) 1D 22. Natonal ID from afer ecuntnes ‘1 Panta Pamiyang Pipino Program (Ps) D 23, Resizence ID fom other counties “The folowing secondary supporting documents MUSThave a rontlazing photograph signatuathumbmark ful name, permanent adress, snd date of bth to be accepted 24 Emaloyes 1D 27. Barangay 0 25 Seo) 28. Givuniegaty 10 28 Barangay CleaancelBarangay Carficate For Resident Allens [For Sess Persons and Retigees: "Vali Foren Passport. and Alen Gerutcate of RegStiabon (RCR) 1. Centcate of Recognitoniseued oy Retugees and 2. Alon Gerfcae of Reaisvation (ACR) or Stoless Porcane Frotoxion Unt /RS°#U) ‘len Certicate of Regstaton entfeation Cid (ACR Car ofthe Department of Justice (004) THIS FORM IS NOT FOR SALE