8/10/2019 Loyalty Card Application (HQP-PFF-108, V01)(1)

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HQP-PFF-108

LOYALTY CARD

APPLICATION FORM(Privilege Card Program)

Pag-IBIG MID NUMBER

REGISTRATION TRACKING NUMBER

INSTRUCTIONS1. Accomplish this form in one (1) copy.2. Type or print all entries in BLOCK or CAPITAL LETTERS.3. The NAME EXTENSION shall refer to JR., II, III and the like.

4. Accomplish only the PRESENT HOME ADDRESS if it is different from thePERMANENT HOME ADDRESS

5. On CONTACT DETAILS portion, indicate at least one (1) contact number.6. All fields which are marked with asterisk (*) are mandatory.

*MEMBERSHIP CATEGORYEmployed Private Overseas Filipino Worker (OFW) For Voluntary MembersEmployed Government Self-Employed (SE) EmployedEmployed Private Household Other Working Group (OWG) Individual Payor (IP)

Other Working Group (OWG), if income is less than P 1,000.00)

MEMBERS PERSONAL DETAILS

*LAST NAME *FIRST NAME *NAME EXT. (e.g., Jr., II) *MIDDLE NAME *MAIDEN NAME (For married women)

*DATE OF BIRTH

m m d d y y y y

*CITIZENSHIP *MARITAL STATUS TAXPAYERS IDENTIFICATION NUMBER (TIN)

- -

SSS/GSIS NUMBER

- -

EMPLOYEE NUMBER

For AFP/PNP Employee, Serial/Badge No.

For DepEd Employee, Division Code-Station Code

COMMON REFERENCE NUMBER (CRN/UMID)

Single/Unmarried

Married

Widow/er

Annulled

Legally Separated

*PLACE OF BIRTH(City/Municipality/Province/Country)(Please indicate country if born outside the Philippines)

*SEXMaleFemale

*MOTHERS MAIDEN NAME

*NAME OF SPOUSE (if married)(Last Name, First Name, Name Ext., Middle Name)

ADDRESS AND CONTACT DETAILS

*PERMANENT HOME ADDRESS (Indicate country code if abroad)COUNTRY + AREA CODE + TELEPHONE NUMBER

Home

*Cell Phone

Business (Direct Line)

Business (Trunk Line) Local

*Email Address

Unit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name

Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code

*PRESENT HOME ADDRESSUnit/Room No., Floor Building Name Lot No., Block No., Phase No. House No. Street Name

Subdivision Barangay Municipality/City Province/State/Country (if abroad) ZIP Code

*PREFERRED MAILING ADDRESS

Present Home Address Permanent Home Address Employer/Business Address

PRESENT EMPLOYMENT DETAILS (If with more than one (1) employer, use separate sheet and follow format below)

*EMPLOYER/BUSINESS NAME MONTHLY INCOME RANGE

Less than P5,000P5,000 to less than P15,000P15,000 to less than P25,000P25,000 to less than P35,000P35,000 to less than P50,000P50,000 or more

*EMPLOYER/BUSINESS ADDRESSUnit/Room No., Floor Building Name Lot No., Block No., Phase No. House No.

Street Name Subdivision Barangay *TYPE OF WORK (For OFWs only)Land-based

(Pls. specify country of assignment) _____________Sea-based

(Pls specify manning agency)__________________

Municipality/City Province *State/Country (if abroad) ZIP Code

*OCCUPATION *NATURE OF WORK/ BUSINESS/ SOURCE OF FUNDS

OFFICE ASSIGNMENT

Head Office Branch ____________

*EMPLOYMENT STATUSPermanent/Regular

Casual

Part-Time/Temporary

Contractual

Project-Based

*FROM

m m y y y y

TO

m m y y y y

*PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG FUND MEMBERSHIP (Use another sheet if necessary)

1

EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT

Head Office Branch ____________

EMPLOYER/BUSINESS ADDRESS FROM

m m y y y y

TO

m m y y y y

2

EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT

Head Office Branch ____________

EMPLOYER/BUSINESS ADDRESS FROM

m m y y y y

TO

m m y y y y

THIS FORM MAY BE REPRODUCED. NOT FOR SALE (Rev. 00, 02/2014)

8/10/2019 Loyalty Card Application (HQP-PFF-108, V01)(1)

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*OTHER INFORMATIONHOME OWNERSHIP

Owned, MortgagedRentingOwned, Not MortgagedLiving with Parents/Relatives

WHAT ARE YOUR FUTURE PLANSFOR YOUR HOME?

Buy/Loan for/Construct a House ofmy Own

Improve/Extend my Current HouseContinue to Rent/Live with RelativesOther ___________________

EDUCATIONAL ATTAINMENT

ElementaryHigh SchoolCollegeMaster/Ph.D.Vocational___________

NO. OF CHILDREN/DEPENDENTSSTILL STUDYING

NO. OF CREDIT CARDS OWNED

NO. OF YEARS IN RESIDENCE NO. OF CARS OWNED

NO. OF TRAVELS ABROAD

Once a Year2 to 5 times per YearMore than 5 times per YearRarelyNever

NO. OF DOMESTIC TRAVELS

Once a Year2 to 5 times per YearMore than 5 times per YearRarelyNever

NO. OF TIMES TO EAT AT ARESTAURANT

Once a Month2 to 5 times per MonthMore than 5 times per MonthRarely

NO. OF TIMES TO GO TO A MALL

Once a Month2 to 5 times per MonthMore than 5 times per MonthRarely

AGREEMENT

I hereby certify that the information given and all statements made herein are true and correct. I agree that the information I have provided may be used or shared with third partiesconducting surveys, marketing activities or promotional offers of Pag-IBIG Fund and its partners. Any promotional offer of Pag-IBIG Fund may be emailed to me at the provided emailaddress. Any telephone calls I make to Pag-IBIG Fund may be monitored and recorded for the purpose of providing quality customer service. In case of falsification, misrepresentationor any similar acts committed by the applicant Pag-IBIG Fund shall automatically suspend the benefits that can be secured through this card indefinitely.

I hereby agree to abide with the terms and conditions of this card program. I hereby agree to maintain my Pag-IBIG Fund membership status active and in good standing to enable meto avail the benefits of this card program. In the event that I do not abide with the terms and conditions of this program, the Pag-IBIG Fund has the right to deny me of any benefit underthis card program.

I hereby authorize the Pag-IBIG Fund, its agents and representatives, upon application for any benefit relating to or under this card program, to conduct investigation deemedappropriate to ascertain my credit standing and financial capability in evaluating availment of such benefit; including but not limited to, request consumer reporting or reference agenciesfor consumer reports of my credit history and to disclose, submit, share or exchange any of my account information and reports to consumer reporting or reference agencies,

government regulatory agencies, other banks, merchant partners or third party. The Credit information may also be transferred to service providers such as TransUnion (TU), BankersAssociation of the Philippines Credit Bureau, Credit Information Corporation, etc.

I hereby agree to the disclosures to be made by Pag-IBIG Fund in connection with this Agreement, provided the same are not contrary to law and public policy.

I hereby acknowledge that I shall bear the cost of my Loyalty Card and hereby allow my employer to collect from me or deduct from my salary the said amount, as payment for the saidcard upon due notice from Pag-IBIG Fund. If the corresponding card fee remains unpaid, I hereby allow Pag-IBIG Fund to deduct from any benefit due me the corresponding card fee/sshould the same remain unpaid.

SIGNATURE OF MEMBER DATE

NOTE: If you do not wish to receive emails containing promotional offers or find any incorrect information, you may send an email at publicaffairs@pagibigfund.gov.phor call Tel. (02) 724-4244.

THIS PORTION IS FOR Pag-IBIG LOYALTY CARD ENROLLMENT KIOSK USE ONLY

RECEIPT OF APPLICATION

APPLICATION THRU TYPE OF ID PRESENTED RECEIVED BY DATE REMARKS

Individual Employer

CONFIRMATION OF APPLICATION

PFR NO. PFR AMOUNT PFR DATE CONFIRMED BY DATE REMARKS

CASHCARD TERMS AND CONDITIONS

1. The Card. LANDBANK (LBP) Cash Card is a card with stored value also known as a PREPAID DEBIT card. It is a non-interest bearing account.2. Card Value.The stored value in the PREPAID DEBIT card expressed in Philippine currency.3. Validity and Renewal. Unless earlier terminated by LBP or returned by the cardholder, the card is valid from date of issuance/renewal and shall be deactivated end of the third

year. The cardholder may request for reactivation by visiting his/her branch of account or thru phone banking facility subject to existing policies on client identification. If no requestfor reactivation is submitted/called-in after one (1) year from the date of deactivation and the card value becomes zero, the card shall be closed. Renewal request at the branch ofaccount/card purchase shall be subject to banking policies. Approval thereof shall, in all cases, be at the sole discretion of LBP.

4. Point of Sale. The card is honored in any establishment with BancNet logo. LBP shall not be liable to the cardholder if, for any reason, the card is not honored.5. Withdrawals. The cardholder can withdraw from any LBP or ExpressNet, Megalink, BancNet member banks ATM.6. Loss of the Card.The cardholder is responsible for the card PINs confidentiality. In case of loss/theft, the cardholder shall immediately call LBP (phone banking or branch of

account) to report the loss/theft. LBP will endeavor to block transactions after the report. However, loss from unblocked transactions after the report and before LBP can implementcomplete blocking shall be for the account of the cardholder.

7. Replacement of Card. LBP will replace a card with inherent defect in the magnetic stripe at no cost. Replacement due to loss/theft, wear and tear shall be subject to replacementfee. The cardholder must surrender the damaged card or submit an affidavit of loss. The replacement card may be claimed after five (5) banking days from receipt of the requestand compliance with requirements.

8. Service Charges and Other Fees.LBP may increase or impose additional charges/fees in providing this service. The cardholder agrees to pay the increase and/or additionalcharges/fees that may be imposed in the future.

9. Perforation of Unclaimed Card.A card that remains unclaimed thirty (30) calendar days from date of receipt by the issuing branch shall be perforated for security reasons.Purchase of a new card shall be required.

10. Limitations on Liability.LBP is not liable for any loss or damage of whatever nature in connection with the use of the card such as, but not limited to, the following instances:a. disruption, failure or delay relating to or in connection with the ATM and Point-of-Sale (POS) functions of the card due to circumstances beyond the control of LBP;b. fortuitous events and force majeure such as, but not limited to, prolonged power outages, breakdown of computers and communication facilities, typhoons, floods, public

disturbances and other similar or related cases;c. loss or damaged which the cardholder may suffer arising out of any unauthorized utilization of the card due to theft or disclosure of PIN or violation of other measures with or

without the cardholders participation;d. inaccurate, incomplete or delayed information received due to disruption or failure of any communication facilities used for the card; ande. indirect, incidental or consequential loss, loss of profit or damage that the cardholder may suffer or has suffered by reason of the use or failure/inability to use the card under the

terms hereof.11. Insurance. THE CASH CARD FUND IS NOT INSURED WITH PDIC.

12. Escheat.Laws on unclaimed balances apply.13. Rules and Regulations.The cardholder agrees to be bound by the rules, regulations and official issuances applicable to this service now existing or which may hereinafter be

issued, as well as, such other terms and conditions governing the use of this service.14. Agreement to the Term s and Condi tions .The cardholders signature herein or the cardholders receipt of the card from the purchaser constitutes the cardholders agreement to

the above terms and condition.

Cardholders/Purchasers signature: ______________________________ Date______________

FOR BANK USE

Name: Cash Card / Account Number:

Reviewed/Checked by: Date Approved by: Date