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FM OO3 01.18 Kabuhayan Beneficiary Profile Form 022023

This document is a beneficiary profile form for the Kabuhayan Program. It collects personal and social security information from beneficiaries, including name, address, civil status, disability status, dependents, social security numbers, and contact information. By signing, the beneficiary certifies that the information is true and correct, understands the profiling purpose, and consents to the use of their personal data as intended without infringing on their privacy rights. Fingerprints may be provided if the beneficiary cannot sign. The form is used to document beneficiary details for a livelihood, formation, enhancement, or assistance project.

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Mary Chris Celoso Medina
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2K views1 page

FM OO3 01.18 Kabuhayan Beneficiary Profile Form 022023

This document is a beneficiary profile form for the Kabuhayan Program. It collects personal and social security information from beneficiaries, including name, address, civil status, disability status, dependents, social security numbers, and contact information. By signing, the beneficiary certifies that the information is true and correct, understands the profiling purpose, and consents to the use of their personal data as intended without infringing on their privacy rights. Fingerprints may be provided if the beneficiary cannot sign. The form is used to document beneficiary details for a livelihood, formation, enhancement, or assistance project.

Uploaded by

Mary Chris Celoso Medina
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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Document Number: Revision No.

Effectivity Date:
FM-OO3-01.18 0 February 23, 2023

KABUHAYAN PROGRAM BENEFICIARY PROFILE FORM

Project ID Number:

PROJECT LOCATION

Region: Province: Municipality/City: District: Barangay: No. & Street Name:

PROJECT DETAILS

☐ Group ☐ Formation ☐ Restoration ☐ ACP


Type of Project: Program Component: Name/Title of Project: Mode of Implementation:
☐ Individual ☐ Enhancement ☐ Direct Admin

PERSONAL INFORMATION
Last First Middle mm/dd/yyyy If yes, specify:
☐ Male
Name: Sex: Birthdate: Civil Status: Have disability?
☐ Female

No. & Street Name Barangay District Municipality/City Province


Home Address: Contact No.: Type of Beneficiary:

Are you a beneficiary of Pantawid Pamilyang Pilipino Program(4Ps)? Yes___ No___

Name of Dependent (Last Name, First Name, Middle Name)

SOCIAL SECURITY

GSIS No.: Pag-IBIG No.: PhilHealth No.: SSS No.: Others, specify:

I certify that the information provided in this form is true and correct. I understand the purpose of this profiling activity and I voluntarily and willfully give my consent to be part of this undertaking. I certify that the information that I will give is true and
correct and that any misrepresentation and falsification of information may void my application to DILP and may result in the retrieval of livelihood assistance. I authorize the use, processing and sharing of my personal data for the purpose that it is
intended for without prejudice to my rights as stated in the Data Privacy Act of 2012.

Registrant is required to affix fingerprints

Signature

Date Signed

If the registrant cannot sign, affix fingerprints in the presence of DOLE personnel.

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