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Get PH GSIS ECRD-2010-02-001-B 2010-2024

GSIS Form No. ECRD-2010-02-001-B Date Revised 2010-02-16 PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN GOVERNMENT SERVICE INSURANCE SYSTEM Financial Center Roxas Boulevard Pasay City 1308 GSIS UMID-eCARD ENROLLMENT FORM With GSIS eCARD PLUS PLEASE CHECK THE TYPE OF MEMBER ACTIVE SURVIVORSHIP PENSIONER OLD AGE PENSIONER LEGAL GUARDIAN Read instructions at the back before accomplishing this form MEMBER S INFORMATION Personal Information Mailing Address/Contact Information First Name Rm/Floor/Unit No. Bldg. Name if applicable Middle Name House or Lot and Block No* Last Name Street Name Suffix i*e* Sr. Jr. III etc* Subdivision Maiden Name if married female employee Brgy/District/Locality Date of Birth DD-MM-YYYY Municipality/City Place of Birth-City Country Postal Code Cell Phone No* Marital Status Home Phone Gender Email Address GSIS ID No* the 11 digit number below your name in the eCard TIN No* Additional Information Office Name Office Address Certified By Signature of Member/Pensioner over Printed Name and Date For active Member Signature of AAO Please bring eCARD and Company ID GSIS PORTION Validated by Enrolled by Date ANNOTATION I hereby certify that the member/applicant named above is physically impaired and no biometrics can be captured* Printed Name of Enrolment Officer / Date GUIDELINES ON FILLING OUT THE ENROLLMENT FORM 1. Use BLOCK letters or UPPER CASE letters in filling out the form 2. Fill-out all information indicated in the form Please do not leave any field blank. For fields not applicable please write N/A 3. For married female member-enrollee indicate your maiden name following the format First Name Middle Name Last Name 4. For date of birth follow the format indicated in the field. Example Date of Birth dd-mm-yyyy should be written as 06-02-1965 5. For field on Height Report this in centimeters cm*. Use these conversion factors 1 ft. 12 in 1 in* 2. 54 cm* Example five feet and 2 inches 5 2 5 x 12 60 in* 2 in* 62 in* x 2. 54 cm* 157. 48 cm* Example 162 lbs. 162 / 2. 2 73. 63 kgs. 7. Distinguishing Features. Limit the distinguishing features to those that can be found on the face. Example Birth marks moles dimples etc* Note Please bring your Office/Agency/Company ID and your eCARD Plus if any or any government issued ID i*e* passport driver s license etc*. Name if applicable Middle Name House or Lot and Block No* Last Name Street Name Suffix i*e* Sr. Jr. III etc* Subdivision Maiden Name if married female employee Brgy/District/Locality Date of Birth DD-MM-YYYY Municipality/City Place of Birth-City Country Postal Code Cell Phone No* Marital Status Home Phone Gender Email Address GSIS ID No* the 11 digit number below your name in the eCard TIN No* Additional Information Office Name Office Address Certified By Signature of Member/Pensioner over Printed Name and Date For active Member Signature of AAO Please bring eCARD and Company ID GSIS PORTION Validated by Enrolled by Date ANNOTATION I hereby certify that the member/applicant named above is physically impaired and no biometrics can be captured* Printed Name of Enrolment Officer / Date GUIDELINES ON FILLING OUT THE ENROLLMENT FORM 1. .

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