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[Annex a.] Application Form (1)

The document is an application form for the Octogenarian, Nonagenarian, and Centenarian Benefit Program under Republic Act No. 11982 in the Philippines. It requires personal, family, and contact information, along with a certification statement for data accuracy and compliance with privacy laws. The form emphasizes the importance of completing all sections and provides guidelines for submission.

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3K views3 pages

[Annex a.] Application Form (1)

The document is an application form for the Octogenarian, Nonagenarian, and Centenarian Benefit Program under Republic Act No. 11982 in the Philippines. It requires personal, family, and contact information, along with a certification statement for data accuracy and compliance with privacy laws. The form emphasizes the importance of completing all sections and provides guidelines for submission.

Uploaded by

oscacapalongacn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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
A.1 LAST NAME

A.2 GIVEN NAME A.3. MIDDLE NAME

A.4. DATE OF BIRTH


(Month/Day/Year)

A.5. RESIDENTIAL ADDRESS


House Number Street Barangay City/Municipality Province Zip Code

A.6. PERMANENT ADDRESS


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)

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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.
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.

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