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    Application Form Unified Multi-Purpose Id (Umid) Card: Social Security System

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    Rhea Mae Amit
    The document is an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. It requests personal information such as name, date of birth, place of birth, parents' names, address, marital status, identification numbers, and physical description. Applicants must present identification documents and consent to their information being used for the UMID system. Instructions are provided on how to fill out the form and which identification documents are accepted.

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    Application Form Unified Multi-Purpose Id (Umid) Card: Social Security System

    Uploaded by

    Rhea Mae Amit
    110 views2 pages
    The document is an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. It requests personal information such as name, date of birth, place of birth, parents' names, address, marital status, identification numbers, and physical description. Applicants must present identification documents and consent to their information being used for the UMID system. Instructions are provided on how to fill out the form and which identification documents are accepted.

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    SSSForms_UMID_Application.pdf

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    The document is an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. It requests personal information such as name, date of birth, place of birth, parents' names, address, marital status, identification numbers, and physical description. Applicants must present identification documents and consent to their information being used for the UMID system. Instructions are provided on how to fill out the form and which identification documents are accepted.

    Copyright:

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

    Application Form Unified Multi-Purpose Id (Umid) Card: Social Security System

    Uploaded by

    Rhea Mae Amit
    The document is an application form for a Unified Multi-Purpose ID (UMID) Card from the Social Security System of the Philippines. It requests personal information such as name, date of birth, place of birth, parents' names, address, marital status, identification numbers, and physical description. Applicants must present identification documents and consent to their information being used for the UMID system. Instructions are provided on how to fill out the form and which identification documents are accepted.

    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


    (07-2013) APPLICATION FORM
    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 Others ____________________
    Replacement of Damaged Card Amendment of Demographic Data __________________________
    Amendment of Name Amendment of Authenticating Finger

    PART I - NAME
    1. NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

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

    (IF MARRIED FEMALE)

    PART II - FACTS OF BIRTH


    2. DATE OF BIRTH (MMDDYYYY) 3. PLACE OF BIRTH (CITY/MUNICIPALITY) (PROVINCE/STATE) (COUNTRY, If born outside the Philippines) 4. SEX

    MALE FEMALE
    5a. FATHER'S NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

    5b. MOTHER'S MAIDEN NAME (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

    PART III - DEMOGRAPHIC DATA


    6. HOME ADDRESS (RM./FLR./UNIT NO. & BLDG. NAME) (HOUSE/LOT & BLK. NO.) (STREET NAME) (SUBDIVISION)

    (BARANGAY/DISTRICT/LOCALITY) (CITY/MUNICIPALITY) (PROVINCE/STATE) ZIP CODE COUNTRY CODE

    7. MARITAL STATUS
    SINGLE MARRIED WIDOWED DIVORCED/ANNULED LEGALLY SEPARATED
    8. TAX IDENTIFICATION NUMBER 9. HEIGHT (IN CENTIMETERS) 10. WEIGHT (IN KILOGRAMS) 11. DISTINGUISHING FEATURE(S)
    (IF ANY)

    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 Multi-
    Purpose 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.

    PRINTED NAME SIGNATURE DATE


    PART V - OTHER ENROLLEE DATA
    SS NUMBER TELEPHONE NUMBER (AREA CODE + TEL. NO.) MOBILE/CELLPHONE NUMBER E-MAIL ADDRESS

    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
    SS NUMBER/COMMON REFERENCE NUMBER NAME OF MEMBER (LAST NAME) (FIRST NAME) (MIDDLE NAME) (SUFFIX)

    PART VI - FOR SSS USE ONLY


    IDENTIFICATION/DOCUMENT/S PRESENTED REMARKS

    SCREENED BY DATA CAPTURED BY

    SIGNATURE OVER PRINTED NAME DATE & TIME BRANCH SIGNATURE OVER PRINTED NAME DATE & TIME
    -------------------------------------------------------------------------------------------------Perforate Here-------------------------------------------------------------------------------------------------
    Republic of the Philippines
    UNIFIED MULTI-PURPOSE ID (UMID) CARD APPLICATION FORM
    ACKNOWLEDGEMENT STUB
    SS NUMBER/COMMON REFERENCE NUMBER NAME OF AGENCY BRANCH

    SOCIAL SECURITY SYSTEM


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

    SCREENED BY DATA CAPTURED BY

    SIGNATURE OVER PRINTED NAME DATE & TIME SIGNATURE OVER PRINTED NAME DATE & TIME
    Perforate here RIGHT THUMB 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 ▪ Professional Regulation Commission (PRC) card
    ▪ Passport ▪ 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
    ▪ Membership Card issued by private companies ▪ Permit to Carry Firearms issued by the Firearms & Explosive Unit of PNP
    ▪ Overseas Worker Welfare Administration Card ▪ PHIC Member's Data Record
    ▪ Senior Citizen Card ▪ Police Clearance
    ▪ Voter's Identification Card/Affidavit/Certificate of Registration ▪ Seafarer's Registration Certificate issued by the Philippine Overseas
    ▪ ATM card Employment Authority (POEA)
    - with cardholder's name ▪ Temporary License issued by Land Transportation Office (LTO)
    - 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:
    ▪ GSIS Card/Member's Record/Certificate of Membership - Office of the Southern/Northern Cultural Communities
    ▪ Health or Medical Card - Office of Muslim Affairs
    ▪ ID Card issued by LGUs (e.g. Barangay/ Municipal/City) ▪ Certificate of Licensure/Qualification Documents/Seafarer's ID & Record
    ▪ ID Card issued by professional association recognized by PRC Book from Maritime Industry Authority
    ▪ Permanent Residency ID ▪ Certificate of Naturalization from the Bureau of Immigration
    ▪ 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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