HQP-PFF-108

LOYALTY CARD
APPLICATION FORM

Pag-IBIG MID NUMBER

REGISTRATION TRACKING NUMBER

(Privilege Card Program)

INSTRUCTIONS
1. 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.

*MEMBERSHIP CATEGORY
Employed Private
Employed Government
Employed Private Household

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

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

Overseas Filipino Worker (OFW)

Self-Employed (SE)
Other Working Group (OWG)

For Voluntary Members

Employed
Individual Payor (IP)
Other Working Group (OWG), if income is less than P 1,000.00)

MEMBERS PERSONAL DETAILS

*LAST NAME

*FIRST NAME

*DATE OF BIRTH
m m
d d
*PLACE OF BIRTH

*NAME EXT. (e.g., Jr., II)

*MIDDLE NAME

*MAIDEN NAME (For married women)

*CITIZENSHIP

*MARITAL STATUS

TAXPAYERS IDENTIFICATION NUMBER (TIN)

Single/Unmarried
Married
Widow/er
Annulled
Legally Separated

(City/Municipality/Province/Country)
(Please indicate country if born outside the Philippines)

*SEX
Male
Female

*MOTHERS MAIDEN NAME

SSS/GSIS NUMBER

EMPLOYEE NUMBER

For AFP/PNP Employee, Serial/Badge No.

For DepEd Employee, Division Code-Station Code

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

COMMON REFERENCE NUMBER (CRN/UMID)

ADDRESS AND CONTACT DETAILS

*PERMANENT HOME ADDRESS
Unit/Room No., Floor

Building Name

Lot No., Block No., Phase No. House No.

Street Name

Subdivision

Barangay

Municipality/City

ZIP Code

Province/State/Country (if abroad)

(Indicate country code if abroad)

COUNTRY + AREA CODE + TELEPHONE NUMBER
Home

*Cell Phone

*PRESENT HOME ADDRESS

Unit/Room No., Floor

Building Name

Lot No., Block No., Phase No. House No.

Street Name

Business (Direct Line)

Subdivision

Barangay

Municipality/City

ZIP Code

Business (Trunk Line)

Province/State/Country (if abroad)

*Email Address

*PREFERRED MAILING ADDRESS

Present Home Address

Local

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

*EMPLOYER/BUSINESS ADDRESS

Less than P5,000

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

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)

*OCCUPATION

*EMPLOYMENT STATUS
Permanent/Regular
Casual

ZIP Code

*NATURE OF WORK/ BUSINESS/ SOURCE OF FUNDS

Part-Time/Temporary
Contractual

*TYPE OF WORK (For OFWs only)

Land-based
(Pls. specify country of assignment) _____________
Sea-based
(Pls specify manning agency)__________________
OFFICE ASSIGNMENT
Head Office

Branch ____________

*FROM

TO

Project-Based
m

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

OFFICE ASSIGNMENT
Head Office

Branch ____________

EMPLOYER/BUSINESS ADDRESS

FROM

TO

EMPLOYER/BUSINESS NAME

OFFICE ASSIGNMENT
Head Office

Branch ____________

FROM

TO

EMPLOYER/BUSINESS ADDRESS

THIS FORM MAY BE REPRODUCED. NOT FOR SALE

(Rev. 00, 02/2014)

*OTHER INFORMATION
HOME OWNERSHIP

WHAT ARE YOUR FUTURE PLANS

FOR YOUR HOME?

EDUCATIONAL ATTAINMENT

NO. OF YEARS IN RESIDENCE

Buy/Loan for/Construct a House of

my Own
Improve/Extend my Current House
Continue to Rent/Live with Relatives
Other ___________________

Elementary
High School
College
Master/Ph.D.
Vocational___________

NO. OF TRAVELS ABROAD

Once a Year
2 to 5 times per Year
More than 5 times per Year
Rarely
Never

NO. OF DOMESTIC TRAVELS

Once a Year
2 to 5 times per Year
More than 5 times per Year
Rarely
Never

NO. OF TIMES TO EAT AT A

RESTAURANT
Once a Month
2 to 5 times per Month
More than 5 times per Month
Rarely

Owned, Mortgaged
Renting
Owned, Not Mortgaged
Living with Parents/Relatives

NO. OF CHILDREN/DEPENDENTS
STILL STUDYING

NO. OF CREDIT CARDS OWNED

NO. OF CARS OWNED

NO. OF TIMES TO GO TO A MALL
Once a Month
2 to 5 times per Month
More than 5 times per Month
Rarely

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 parties
conducting 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 email
address. 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, misrepresentation
or 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 me
to 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 under
this 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 deemed
appropriate to ascertain my credit standing and financial capability in evaluating availment of such benefit; including but not limited to, request consumer reporting or reference agencies
for 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), Bankers
Association 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 said
card 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/s
should 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.ph or call Tel. (02) 724-4244.

APPLICATION THRU
Individual

THIS PORTION IS FOR Pag-IBIG LOYALTY CARD ENROLLMENT KIOSK USE ONLY
RECEIPT OF APPLICATION
TYPE OF ID PRESENTED
RECEIVED BY
DATE
REMARKS

Employer

PFR NO.

PFR AMOUNT

CONFIRMATION OF APPLICATION
PFR DATE
CONFIRMED BY

DATE

REMARKS

CASHCARD TERMS AND CONDITIONS

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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.
Card Value. The stored value in the PREPAID DEBIT card expressed in Philippine currency.
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 request
for 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 of
account/card purchase shall be subject to banking policies. Approval thereof shall, in all cases, be at the sole discretion of LBP.
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.
Withdrawals. The cardholder can withdraw from any LBP or ExpressNet, Megalink, BancNet member banks ATM.
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 implement
complete blocking shall be for the account of the cardholder.
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 replacement
fee. 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 request
and compliance with requirements.
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 additional
charges/fees that may be imposed in the future.
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.
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; and
e. 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.
Insurance. THE CASH CARD FUND IS NOT INSURED WITH PDIC.
Escheat. Laws on unclaimed balances apply.
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.
Agreement to the Terms and Conditions. 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: ______________________________

FOR BANK USE

Cash Card / Account Number:

Name:
Reviewed/Checked by:

Date______________

Date

Approved by:

Date