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    [Annex A.] Application Form

    Uploaded by

    sherliedluben
    Application senior citizen

    Copyright:

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

    [Annex A.] Application Form

    Uploaded by

    sherliedluben
    93 views2 pages
    Application senior citizen

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Application senior citizen

    Copyright:

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

    [Annex A.] Application Form

    Uploaded by

    sherliedluben
    Application senior citizen

    Copyright:

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

    Annex “A”

    Republic of the Philippines


    Office of the President
    NATIONAL COMMISSION OF SENIOR CITIZENS
    4th Floor, AAP Tower, 683 Aurora Blvd, Mariana, 1117 Quezon City, Philippines
    Official website: www.ncsc.gov.ph

    APPLICATION FORM
    OCTOGENARIAN, NONAGENARIAN AND CENTENARIAN BENEFIT PROGRAM

    PURPOSE: To claim the benefits under Republic Act (R.A.) No. 11982.

    INSTRUCTIONS:
    1. Fill out this form completely and correctly.
    2. Do not leave any blank space. If not applicable, kindly indicate "N/A". “2X2 ID Picture”
    3. Write in BLOCK letters.

    This application form is not for sale.


    A. PERSONAL INFORMATION
    NCSC REGISTRATION REFERENCE NUMBER (RRN) OSCA ID NUMBER

    A.1 LAST NAME

    A.2 GIVEN NAME A.3. MIDDLE NAME

    A.4. DATE OF BIRTH


    (Month/Day/Year)

    A.5. RESIDENTIAL ADDRESS/ADDRESS ABROAD


    House Number Street Barangay City/Municipality Province Zip Code

    A.6. PERMANENT ADDRESS IN THE PHILIPPINES


    House Number Street Barangay City/Municipality Province Zip Code

    A.7. SEX A.8. CIVIL STATUS A.9. CITIZENSHIP


    ☐ Male ☐ Female ☐ Single ☐ Widowed ☐ Filipino
    ☐ Others:
    ☐ Married _______ ☐ Dual citizen
    If dual citizen, kindly
    indicate
    details:
    ________________

    B. FAMILY INFORMATION
    B.1. NAME OF SPOUSE B.2. CITIZENSHIP
    (LAST NAME, GIVEN NAME, FULL MIDDLE NAME)

    Page 1 of 2
    B.3. NAME OF CHILDREN
    (LAST NAME, GIVEN NAME, FULL MIDDLE NAME)

    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.
    10.
    B.4 AUTHORIZED REPRESENTATIVE/S
    Name of Representative/s Relationship
    B.4.1
    B.4.2
    B.4.2
    C. CONTACT INFORMATION
    C.1. CONTACT NUMBERS C.2. EMAIL ADDRESS
    (TELEPHONE AND MOBILE NUMBERS)

    D. CERTIFICATION
    I hereby certify under oath that all the information in this application form are true and correct. I authorize the
    verification of the information provided in this form as well as the usage and processing of the information by
    the National Commission of Senior Citizens in accordance with the R.A. No. 10173, otherwise known as the
    “Data Privacy Act of 2012”, its Implementing Rules and Regulations, and issuances of the National Privacy
    Commission. I further warrant that I have complied with all the requirements and I have presented all pertinent
    documentary requirements. I understand that my application shall not be processed if any statement herein
    made is found to be false, or if any document I submitted is found to have been falsified, or if I fail to comply
    with all the requirements with respect to my application, without prejudice to whatever actions that may be taken
    against me in accordance with the applicable laws of the Republic of the Philippines. Further, I hereby certify
    that I have not commenced the application/processing for the cash benefits as provided for under R.A. No.
    11982 before any government agency.
    NAME AND SIGNATURE/THUMBMARK OF APPLICANT

    DATE OF APPLICATION

    SUBSCRIBED AND SWORN TO BEFORE ME, this ______ day of _______________________, at


    _____________________, the affiant exhibited to me his/her _________________ with ID number
    __________________, issued at ____________________, on ___________________, valid until
    ________________________.

    Doc. No. _______;


    Page No. _______; NOTARY PUBLIC
    Book No. _______;
    Series of _______.

    DATA PRIVACY
    In compliance with the provisions of R.A. No. 10173, otherwise known as the “Data Privacy Act of 2012”, its
    Implementing Rules and Regulations, and issuances of the National Privacy Commission, the National
    Commission of Senior Citizens ensures that the personal information provided is collected, used, and processed
    by its authorized personnel and shall only be used for the implementation of R.A. No. 11982.

    Page 2 of 2

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