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NATIONAL COMMISSION OF SENIOR CITIZENS
ONLINE SENIOR CITIZEN
DATA FORM
New Application
Please fill up completely and correctly the required
information before each item below. For items that are not
associated to you, leave it blank. Required items are also
marked with an asterisk (*) so please fill it up correctly. Your
honest response will help the National Commission of
Senior Citizens (NCSC) come up with a good information
system of the senior citizens in the country as the basis of
designing its programs and activities that will help improve
the lives of Filipino older persons.
* Items with an asterisk (*) are required.
I. IDENTIFYING INFORMATION
1. Name - Enter your name correctly
Lastname (Apelyido) *
Navarro
Firstname (Pangalan) *
Rosalinda
Middlename (Gitnang Pangalan) *
Ocaña
Extension
I have name extension
2. Address - Select region first, and then
province, then city, and finally your barangay
Region *
REGION IV-A
Province *
CAVITE
City *
GENERAL TRIAS
Barangay *
MANGGAHAN
...
Residence (House No./Block/Lot) *
216 bagong pook
Street (Zone/Purok/Sitio) - Not required
Manggahan general trias cavite
3. Birth Date - Indicate your birth date
correctly
Month *
May
Date *
22
Year *
1951
Click here to check for your age.
4. Birth Place
5. Marital Status *
6. Religion
7. Sex at Birth *
8. Contact Number *
9a. Email Address - (Put NONE if there is
no email) *
9b. FB Messenger Name
10. Ethnic Origin
11. Language Spoken
12. OSCA ID No.
13. GSIS/SSS No.
14. TIN
15. PhilHealth No.
16. SC Association ID No.
17. Other Gov't ID No.
18. Employment / Business
19. Current Pension
20. Capability to Travel
II. FAMILY COMPOSITION
21. Name of your spouse
Lastname
Firstname
Middlename
Name Extension
22. Name of your father
Lastname
Firstname
Middlename
Name Extension
23. Name of your mother
Lastname
Firstname
Middlename
Name Extension
24. Name of your child(ren) - If
applicable, enumerate the first five and
arrange them from oldest to youngest
Complete Name
1. Child Name
Occupation
Occupation
Income (Optional)
Income
Age Is Working?
Age Is working?
2. Child Name
Occupation
Income
Age Is Working?
3. Child Name
Occupaton
Income
Age is Working?
4. Child Name
Occupation
Income
Age Is Working?
5. Child Name
Occupation
Income
Age Is Working?
24.a Other Dependents - If applicable,
specify your dependents below.
Dependents are those living with you
1. Name of Dependent
Occuption of Dependent
Income
Age Is Working?
2. Name of Dependent
Occupation of Dependent
Income
Age Is Working?
III. DEPENDENCY PROFILE
25. Living Condition (Check all applicable)
Living Alone
Living with
Grand Children
Common Law Spouse
Spouse
In-laws
Care Institution
Children
Relatives
Friends
Others
Specify
26. Living Condition (Check all
applicable)
No privacy
Overcrowded in home
Informal Settler
No permanent house
High cost of rent
Longing for independent living
quiet atmosphere
Others
Others, Specify
IV. EDUCATION / HR PROFILE
27. Highest Educational
Attainment
Not Attended School
Elementary Level
Elementary Graduate
Highschool Level
Highschool Graduate
Vocational
College Level
College Graduate
Post Graduate
Others, Specify
28. Specialization / Technical Skills
(Check all applicable)
Medical
Dental
Fishing
Engineering
Barber
Evangelization
Millwright
Teaching
Counselling
Cooking
Carpenter
Mason
Tailor
Legal Services
Farming
Arts
Plumber
Shoemaker
Chef/Cook
Information Technology
Others, Specify
29. Shared Skills (Community Service)
Type skills here separated by comma
30. Involvement in Community
Activities (Check all applicable)
Medical
Resource Volunteer
Community Beautification
Community / Organization
Leader
Dental
Friendly Visits
Neighborhood Support Services
Legal Services
Religious
Counselling / Referral
Sponsorship
Others, Specify
V. ECONOMIC PROFILE
31. Source of Income and Assistance
(Check all applicable)
Own earnings, salary / wages
Own Pension
Stocks / Dividends
Dependent on children / relatives
Spouse's salary
Spouse Pension
Insurance
Rental / Sharecorp
Savings
Livestock / orchard / farm
Fishing
Others, Specify
32.A Assets: Real and Immovable
Properties (Check all applicable)
House
Lot / Farmland
House & Lot
Commercial Building
Fishpond / resort
Others, Specify
32.B Assets: Personal and Movable
Properties
Automobile
Personal Computer
Boats
Heavy Equipment
Laptops
Drones
Motorcycle
Mobile Phones
Others, Specify
33. Monthly Income (in Philippine Peso)
This item is optional
60000 and above
50000 to 60000
400000 to 50000
30000 to 40000
20000 to 30000
10000 to 20000
5000 to 10000
below 5000
None
34. Problems / Needs Commonly
Encountered (Check all applicable)
Lack of income / resources
Loss of income / resources
Skills / capability training
(specify)
Livelihood Opportunties (Specify)
Others, Specify
VI. HEALTH PROFILE
35.a Medical Concern
Blood Type *
Physical Disability
Physical Disability type here
Health Problems / Ailments
Hypertension
Arthritis / Gout
Coronary Heart Disease
Diabetes
Chronic Kidney Disease
Alzheimer's / Dementia
Chronic Obstructive Pulmonary
Disease
Others, Specify
35.b Dental Concern
Needs Dental
Care
Others, Specify
35.c Visual Concern
Eye impairment
Needs eye care
Others, Specify
35.d Aural/Hearing Condition
Aural impairment
Others, Specify
35.e Social / Emotional
Feeling neglect / rejection
Feeling helplessness / worthlessness
Feeling loneliness / isolate
Lack leisure / recreational activities
Lack SC friendly environment
Others, Specify
35.f Area of Difficulty
High Cost of medicines
Lack of medicines
Lack of medical attention
Others, Specify
36. List of Medicines for Maintenance
(Type all your maintenance medicines.
Example : Amlodiphne 10mg, Losartan
50mg, etc.)
37. Do you have a scheduled
medical/physical check-up?
37.A If Yes, when is it done?
OSCA ID AND PHOTO
ATTACHMENT
ATTACH IMAGE OF YOUR OSCA* ID
* Office of Senior Citizens Affairs (OSCA)
Please take an image or picture of your
OSCA-ID or any government ID and attach
it here. To attach the image file, take a picture of
your OSCA ID and then click on the "Upload your
ID" button to locate the image file from your local
drive or mobile.
If you don't have an OSCA ID then you
can attach any valid ID you have in your
possesion.
Upload/take photo of your ID
Image must not exceed 50MB
ATTACH YOUR ACTUAL PHOTO
To attach your captured photo, take your actual
picture or selfie using your mobile phone and
click on the Upload button below and locate the
photo file from your device to upload it here. We
need a close-up image of your face, so please
take a 2x2 size photo capture only.
Please take a selfie of your face. Do not
attach a whole-body picture or your
younger-year photo, we need the actual
senior photo of your face only.
Upload/Take Photo
Image must not exceed 50MB
PASS KEY NUMBER
Create your own Pass Key
Number * (PKN)
Please create your own PKN for your registration
below. You will need this to access and verify
your record later. The maximum combination for
the nominated PKN is four (4) digits only.
Enter PKN
Type here...
Re-enter PKN
Re-type here ...
Warning : Make sure to remember and
take note of your PKN before
submitting.
CONFIRMATION TO ALLOW
THE STORAGE AND USE OF MY
PERSONAL DATA
This is to certify
that
The information entered above is true
and correct.
I have the full knowledge in providing the
above information.
I understand the purpose of enrolling
myself in the registry of the National
Commission of Senior Citizens.
I have personally given my consent to
allow the use of the information
contained in this form.
I understand that this form contains my
personal information to be stored in the
NCSC senior citizens database.
I have certified further that during the
filling-out of this form, I was assisted by
the person whose name is indicated
below and that such person is personally
known to me.
Assisted by
Type here the complete name of the …
Relation to the registrant /
Contact No.
Type the relation here
Proceed to Submit
Cancel
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