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    SSSForms UMID Application

    Uploaded by

    Romer Bryan De Castro
    This document is a summary of an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. The form collects personal information such as name, date of birth, place of birth, parents' names, address, marital status, height, weight, distinguishing features, and consent for the data to be used and secured for the UMID system. Instructions are provided on how to fill out the form correctly and what identification documents are required.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    SSSForms UMID Application

    Uploaded by

    Romer Bryan De Castro
    3K views2 pages
    This document is a summary of an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. The form collects personal information such as name, date of birth, place of birth, parents' names, address, marital status, height, weight, distinguishing features, and consent for the data to be used and secured for the UMID system. Instructions are provided on how to fill out the form correctly and what identification documents are required.

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    This document is a summary of an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. The form collects personal information such as name, date of birth, place of birth, parents' names, address, marital status, height, weight, distinguishing features, and consent for the data to be used and secured for the UMID system. Instructions are provided on how to fill out the form correctly and what identification documents are required.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views2 pages

    SSSForms UMID Application

    Uploaded by

    Romer Bryan De Castro
    This document is a summary of an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. The form collects personal information such as name, date of birth, place of birth, parents' names, address, marital status, height, weight, distinguishing features, and consent for the data to be used and secured for the UMID system. Instructions are provided on how to fill out the form correctly and what identification documents are required.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Republic of the Philippines

    UNIFIED MULTI-PURPOSE ID (UMID) CARD


    APPLICATION FORM

    (07-2013)

    THIS FORM IS NOT FOR SALE AND CAN BE REPRODUCED


    PLEASE READ THE INSTRUCTIONS AT THE BACK BEFORE FILLING OUT THIS FORM. PRINT ALL INFORMATION IN CAPITAL LETTERS AND USE BLACK OR
    BLUE INK ONLY.
    NAME OF AGENCY

    COMMON REFERENCE NUMBER (IF ANY)

    SOCIAL SECURITY SYSTEM


    PURPOSE

    INITIAL ENROLLMENT

    CARD REPLACEMENT
    Replacement of Lost Card

    Amendment of Facts of Birth


    Amendment of Demographic Data

    Replacement of Damaged Card


    Amendment of Name

    Others ____________________
    __________________________

    Amendment of Authenticating Finger

    PART I - NAME
    (LAST NAME)

    1. NAME

    (FIRST NAME)

    DE CASTRO

    ROMER BRYAN

    (LAST NAME)

    MAIDEN NAME

    (MIDDLE NAME)

    (SUFFIX)

    SALABAO

    (FIRST NAME)

    (MIDDLE NAME)

    (SUFFIX)

    (IF MARRIED FEMALE)

    PART II - FACTS OF BIRTH


    2. DATE OF BIRTH (MMDDYYYY)

    0 8

    0 1

    1 9

    (CITY/MUNICIPALITY)

    3. PLACE OF BIRTH

    9 2

    4. SEX
    MALE

    (FIRST NAME)

    DE CASTRO

    5b. MOTHER'S MAIDEN NAME

    (COUNTRY, If born outside the Philippines)

    STA. MESA, MANILA


    (LAST NAME)

    5a. FATHER'S NAME

    (PROVINCE/STATE)

    (LAST NAME)

    SALABAO

    (MIDDLE NAME)

    ROMEO

    RAMOS

    (FIRST NAME)

    (MIDDLE NAME)

    ERLINDA

    FEMALE

    (SUFFIX)

    (SUFFIX)

    NIEVES

    PART III - DEMOGRAPHIC DATA


    (RM./FLR./UNIT NO. & BLDG. NAME)

    6. HOME ADDRESS

    (HOUSE/LOT & BLK. NO.)

    1807

    (BARANGAY/DISTRICT/LOCALITY)

    (CITY/MUNICIPALITY)

    BRGY. 570, ZONE 56

    SAMPALOC, MANILA

    (STREET NAME)

    (SUBDIVISION)

    MINDANAO AVE. EXT


    (PROVINCE/STATE)

    ZIP CODE

    0 0 8

    COUNTRY CODE

    +63

    7. MARITAL STATUS

    x SINGLE
    MARRIED
    WIDOWED
    DIVORCED/ANNULED
    11. DISTINGUISHING FEATURE(S)
    8. TAX IDENTIFICATION NUMBER 9. HEIGHT (IN CENTIMETERS) 10. WEIGHT (IN KILOGRAMS)

    LEGALLY SEPARATED

    (IF ANY)

    4 3 8

    6 5 6

    0 4 6

    175 cm

    70 kg
    PART IV - STATEMENT OF CONSENT

    I declare that I am fully aware that the above data shall be used for securing my Common Reference Number (CRN) for the Unified MultiPurpose ID (UMID) System or updating my personal data in the CRN Registry. I trust that the above data shall remain confidential, hence, I give
    my consent that the same data be secured and accessed for subsequent validation, verification and other purpose consistent with the objectives
    of the UMID System under Executive Order No. (EO) 420 as amended by EO No. 700. I further affirm that all statements/data, which appear in
    this application form and made by me are true, correct and complete to the best of my knowledge and belief.

    ROMER BRYAN DE CASTRO


    PRINTED NAME

    SIGNATURE

    DATE

    PART V - OTHER ENROLLEE DATA


    TELEPHONE NUMBER (AREA CODE + TEL. NO.)

    SS NUMBER

    3 4

    4 0 1

    8 2 9 1

    MOBILE/CELLPHONE NUMBER

    9 3 2

    7 3 7 4

    E-MAIL ADDRESS

    9 5 [email protected]

    IF YOU ARE A SURVIVING SPOUSE/GUARDIAN/DEPENDENT OF DECEASED/PENSIONER MEMBER, PLEASE INDICATE SS NUMBER/COMMON REFERENCE
    NUMBER (IF ANY) OF DECEASED/PENSIONER MEMBER BELOW
    (LAST NAME)
    (FIRST NAME)
    (MIDDLE NAME)
    (SUFFIX)
    SS NUMBER/COMMON REFERENCE NUMBER
    NAME OF MEMBER

    PART VI - FOR SSS USE ONLY


    IDENTIFICATION/DOCUMENT/S PRESENTED

    REMARKS

    SCREENED BY

    DATA CAPTURED BY

    DATE & TIME


    SIGNATURE OVER PRINTED NAME
    BRANCH
    SIGNATURE OVER PRINTED NAME
    DATE & TIME
    -------------------------------------------------------------------------------------------------Perforate Here-------------------------------------------------------------------------------------------------

    Republic of the Philippines

    UNIFIED MULTI-PURPOSE ID (UMID) CARD APPLICATION FORM

    ACKNOWLEDGEMENT STUB
    NAME OF AGENCY

    SS NUMBER/COMMON REFERENCE NUMBER

    3 4

    4 0 1

    NAME

    8 2 9

    1 -

    SOCIAL SECURITY SYSTEM

    (LAST NAME)

    (FIRST NAME)

    DE CASTRO

    ROMER BRYAN

    SCREENED BY

    SIGNATURE OVER PRINTED NAME

    BRANCH

    WELCOME ROTONDA, ESPAA


    (MIDDLE NAME)

    (SUFFIX)

    SALABAO

    N/A

    DATA CAPTURED BY

    DATE & TIME

    SIGNATURE OVER PRINTED NAME

    Perforate here

    RIGHT THUMB

    DATE & TIME

    RIGHT INDEX

    INSTRUCTIONS
    1. This form shall be used in applying for initial or replacement UMID card.
    2. Fill out this form in one (1) copy without erasures and alterations.
    3. Place a checkmark on the applicable box.
    4. Always indicate "N/A" or "Not Applicable", if the required data is not applicable.
    5. Present identification document/s.
    a. Any one (1) of the following primary documents:
    Driver's License
    Passport

    Professional Regulation Commission (PRC) card


    Seaman's Book

    b. In the absence of the primary documents, submit any two (2) of the following secondary documents, one of which with signature and photo:
    Postal ID
    Marriage Contract
    School or Company ID
    NBI Clearance
    Taxpayer's Identification Number (TIN) card
    Pag-IBIG Member's Data Form
    Permit to Carry Firearms issued by the Firearms & Explosive Unit of PNP
    Membership Card issued by private companies
    Overseas Worker Welfare Administration Card
    PHIC Member's Data Record
    Senior Citizen Card
    Police Clearance
    Seafarer's Registration Certificate issued by the Philippine Overseas
    Voter's Identification Card/Affidavit/Certificate of Registration
    Employment Authority (POEA)
    ATM card
    Temporary License issued by Land Transportation Office (LTO)
    - with cardholder's name
    - with certification from bank, if without name
    Transcript of School Records
    Credit card
    Alien Certificate of Registration
    Fisherman's Card issued by the Bureau of Fisheries and
    Bank Account Passbook
    Aquatic Resources (BFAR)
    Certificate from:
    - Office of the Southern/Northern Cultural Communities
    GSIS Card/Member's Record/Certificate of Membership
    - Office of Muslim Affairs
    Health or Medical Card
    ID Card issued by LGUs (e.g. Barangay/ Municipal/City)
    Certificate of Licensure/Qualification Documents/Seafarer's ID & Record
    Book from Maritime Industry Authority
    ID Card issued by professional association recognized by PRC
    Certificate of Naturalization from the Bureau of Immigration
    Permanent Residency ID
    Birth Certificate
    Life Insurance Policy
    Baptismal Certificate
    Birth/Baptismal certificate of child/ren or its equivalent
    6. Fill out appropriate items in the following format:
    a. Items 1, 5a and 5b
    Example: Juan Andres Gregorio Toralba III will be entered as:

    b. Item 1 (For Married Female)


    Example: Anna Maria Dela Cruz Santos at birth and married name is Anna Maria Roman will be entered as:

    c. Item 6
    Example: 837 Akle St., Barangay Claro, Project 2, Quezon City 1102 will be entered as:

    Indicate the permanent address rather than the temporary mailing address. For example, if with permanent residence in the province but
    working or staying in Metro Manila during weekdays, indicate the provincial address instead of the Metro Manila address.
    7. Write the "Height" in centimeters and "Weight" in kilograms.
    To convert:
    1 ft = 30.38 cm
    1 lb = 0.4536 kg
    1 in = 2.54 cm
    8. In item 11, limit the distinguishing features to those that can be found on the face such as "mole under the right eye" and "mole or birth mark on the
    left cheek/forehead".
    9. For card replacement, pay the required fee at any SSS branch office/accredited bank/collecting agent and submit this form together with the required
    document/s and validated Miscellaneous Payment Form or Special Bank Receipt (SBR) with Miscellaneous Payment Form to the nearest SSS branch
    office.
    10. For card replacement due to amendment of data/authenticating finger, submit the previously issued SSS or UMID card.

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