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Form 1A FRONT v1 2

This document is a registration form for the Philippine Identification System (PhilSys). It collects personal information such as name, date of birth, address, and identification documents from applicants to issue a PhilID card. Applicants provide their consent for their data to be used to obtain a PhilSys Number, issue a PhilID, and update their demographic and biometric information in the PhilSys registry. The form collects information that will be printed on the PhilID card and handles like address, signature, and identification documents. It also specifies how the PhilID card will be delivered and discloses how the personal data will be used and stored confidentially according to Philippine law.

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Lira May Lachica
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551 views1 page

Form 1A FRONT v1 2

This document is a registration form for the Philippine Identification System (PhilSys). It collects personal information such as name, date of birth, address, and identification documents from applicants to issue a PhilID card. Applicants provide their consent for their data to be used to obtain a PhilSys Number, issue a PhilID, and update their demographic and biometric information in the PhilSys registry. The form collects information that will be printed on the PhilID card and handles like address, signature, and identification documents. It also specifies how the PhilID card will be delivered and discloses how the personal data will be used and stored confidentially according to Philippine law.

Uploaded by

Lira May Lachica
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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PhilSys Form No.

1A v1 THIS FORM IS NOT FOR SALE

PhilSys Registration Form 1A


FOR 5 YEARS OLD AND ABOVE
Please read the instructions at the back before filling out this form. Print all information in CAPITAL letters
and use BLACK ink only. Place an "X" mark on the applicable items.
1 NAME
THIS INFORMATION WILL BE PRINTED ON THE PHILID CARD

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


2 SEX 3 DATE OF BIRTH

MALE FEMALE - -
Y Y Y Y M M D D
4 PLACE OF BIRTH

(CITY/MUNICIPALITY) (PROVINCE) (COUNTRY)


5 BLOOD TYPE 6 FILIPINO OR RESIDENT ALIEN
TYPE: UNKNOWN
FILIPINO RESIDENT ALIEN
7 MARITAL STATUS (OPTIONAL)
SINGLE MARRIED WIDOWED DIVORCED LEGALLY SEPARATED
ANNULLED NULLIFIED
8 A. PERMANENT ADDRESS

(RM/FLR/UNIT NO. BLDG NAME) (HOUSE/LOT/BLOCK NO.) (STREET) (SUBDIVISION)

(BARANGAY) (CITY/MUNICIPALITY) (PROVINCE/STATE) (COUNTRY)


B. PRESENT ADDRESS (OPTIONAL) SAME AS PERMANENT ADDRESS
FOR PROCESSING PURPOSES ONLY

(RM/FLR/UNIT NO. BLDG NAME) (HOUSE/LOT/BLOCK NO.) (STREET) (SUBDIVISION)

(BARANGAY) (CITY/MUNICIPALITY) (PROVINCE) (COUNTRY)


9 MOBILE NUMBER (OPTIONAL) 10 EMAIL ADDRESS (OPTIONAL)

PhilSys notification will be sent through the provided mobile number. PhilSys notification will be sent through the provided email address.
11 SUPPORTING DOCUMENT/S PRESENTED (Indicate the document/s presented as listed at the back of the Form.)
TYPE OF DOCUMENTS BReN/ID Number/ACR I-Card Number
1
2
12 MODE OF PHILID DELIVERY
DELIVER TO PERMANENT ADDRESS DELIVER TO PRESENT ADDRESS
DISCLOSURE UNDER SECTION 12 OF DATA PRIVACY ACT OF 2012 (RA No. 10173):
I hereby declare that I am fully aware that the above data shall be used for securing a PhilSys Number (PSN) under the
Philippine Identification System, issuance of PhilID, authentication and/or updating my demographic and biometric information
in the PhilSys Registry. I trust that the above information shall remain confidential, hence, I give my consent that the same data
be accessed for subsequent validation, verification, and other purposes consistent with the objectives of the PSA under RA No.
11055. I further affirm that all statements/information appearing in this registration form are made by me, true, correct, and
complete to the best of my knowledge and belief.
(FOR the Applicant who CANNOT SIGN, AFFIX fingerprints
in the presence of a PhilSys Registration Personnel.)

APPLICANT'S SIGNATURE OVER PRINTED NAME


(Must be signed in the presence of a PhilSys Registration Personnel)

DATE LEFT THUMB RIGHT THUMB


FOR THE USE OF THE PHILIPPINE STATISTICS AUTHORITY ONLY. PLEASE DO NOT WRITE BELOW THIS LINE.
SCREENER ENCODER BIOMETRIC EXCEPTIONS
(To be filled out by the Supervisor)
FRONT FACING PHOTOGRAPH IRIS SCAN
FINGERPRINTS Left Iris
Specify: _________________ Right Iris

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME DATE:

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