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Concessionary Card Form

The document is an application form for concession cards for senior citizens and persons with disabilities. It requests information such as name, date of birth, address and contact details from applicants. A privacy notice is also included stating that personal information will be collected and processed to assess eligibility for the concession cards.

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jsus22
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325 views2 pages

Concessionary Card Form

The document is an application form for concession cards for senior citizens and persons with disabilities. It requests information such as name, date of birth, address and contact details from applicants. A privacy notice is also included stating that personal information will be collected and processed to assess eligibility for the concession cards.

Uploaded by

jsus22
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CONCESSIONARY CARD

APPLICATION FORM
1 TYPE OF CONCESSIONARY CARD APPLICATION
Mark  the  appropriate  box  with  an  (X)                                                                                      Date  
      of  Registration:  
Markahan  ng  (X)  ang  kaukulang  kahon    
Place  of  Registration:  

☐  Senior  Citizen  beep™  Card                      


☐  New  Registration  
☐  Person  with  Disability  (PWD)  beep™  Card  
☐  Replacement  
☐  Other:  ____________________________  
Senior  Citizen  ID  Number  
 
or  PWD  ID  Number    
2 APPLICANT DETAILS
Family  Name  /  Surname  (Apelyido)  
 
First  Name  /  Given  Name  (Pangalan)  
 
Middle  Name/Maiden  Name  (Panggitnang  Apelyido)  
 
Gender   ☐ Male  (Lalaki) ☐ Female  (Babae)
Date  of  Birth   Month   Day   Year  
(Kapanganakan)   (Buwan) (Araw)   (Taon)  
Address  (Tirahan)  
 
 
Contact  Number  (Telepono  sa  Bahay  o  Numero  ng  Cellphone)  
 
 

CONCESSIONARY CARD CLAIM To  be  filled  out  b y  Transport  Establishment  


STUB personnel:  
Please  present  this  Claim  Stub  to  the  Station  Teller               CLAIM  DATE:  _____________________  
™
when  you  pick  up  your  Concessionary  beep  card.   PAYMENT  MADE?      ☐YES  
 
Name    
Date  Registered    
 
Place  of  Registration  
 
 
 
 
PRIVACY  NOTICE  AND  DECLARATION  (Please  Read  and  Sign)  
 
AF   Payments   Inc.,   the   issuer   of   the   Concessionary   beep™   Card,   is   collecting   and   processing   your  
personal  information  to  facilitate  the  assessment  of  your  eligibility  for,  and  issuing  and  administration  
of   a   Concessionary   beep™   Card.     Where   necessary,   AF   Payments   Inc.   may   disclose   your   personal  
information   to   the   Department   of   Transportation   and   Communications   (DOTC)   and   the   Public  
Transport   Operators   (PTOs)   for   purposes   associated   with   the   administration   of   public   transport  
ticketing  laws.  At  all  times,  your  personal  information  will  be  used  or  disclosed  by  AF  Payments  Inc.  
only  in  accordance  with  applicable  law.    
 
If  you  choose  not  to  provide  certain  information  (such  as  your  name,  address  or  contact  details)  as  
requested,  AF  Payments  Inc.  may  be  unable  to  process  your  application  for  a  Concessionary  beep™  
Card.    
 
I  agree  to  the  terms  and  conditions  set  out  in  this  form,  and  acknowledge  that  I  have  read  the  Privacy  
Notice  and  Declaration.  

Signature  or  Thumb  Print    


of  Applicant  /  Approved  Representative  

Important  reminder:  
The  concessionary  card  fee  (Php20.00)  in  case  of  duplicate  application  is  non-­‐refundable.    Duplicate  
application  will  not  be  processed  and  the  card  fee  will  not  be  refunded.  
 
 
For  Transport  Establishment  Use  Only.  Please  do  not  write  in  this  portion.  

Station  Teller’s  Name  


 
Station  Supervisor’s  Name  
 

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