HQP-PFF-039
(V10, 04/2023)
FOR Pag-IBIG Fund USE ONLY
MEMBER'S DATA FORM Pag-IBIG MID NO.
(MDF) 121307643341
REGISTRATION TRACKING NO.
922259763731
OCCUPATIONAL STATUS EMPLOYED
MEMBERSHIP CATEGORY EMPLOYED - GOVERNMENT Please specify
PERSONAL DETAILS
NAME NO MIDDLE
NAME LAST NAME FIRST NAME MIDDLE NAME
EXTENSION NAME
MEMBER BASILISCO MARJUN CABUSAS
FATHER BASILISCO FELIX VIVAS
MOTHER (Maiden Name) CABUSAS MIAME ROSALITA
SPOUSE (if Married)
MEMBER'S NAME AS
APPEARING IN THE BIRTH BASILISCO MARJUN CABUSAS
CERTIFICATE
DATE OF BIRTH MARITAL STATUS TAXPAYER IDENTIFICATION
10/25/1990 SINGLE/UNMARRIED NUMBER (TIN)
PLACE OF BIRTH CITIZENSHIP SSS NUMBER
PAGADIAN CITY, ZAMBOANGA DEL SUR FILIPINO GSIS NUMBER
SEX HEIGHT(cm) WEIGHT(kg) PROMINENT DISTINGUISHING FACIAL FEATURES EMPLOYEE NUMBER
MALE 0.00 63.00 For AFP/PNP Employee , Serial/Badge
COMMON REFERENCE NUMBER (CRN) FREQUENCY OF MEMBERSHIP SAVINGS (MS) PAYMENT No.
For DepEd Employee ,
-
Division Code-Station Code
ADDRESS AND CONTACT DETAILS
PERMANENT HOME ADDRESS COUNTRY + AREA CODE + TELEPHONE NUMBER
Unit/Room No., Floor Building Name Home
Lot No., Block No., Phase No. House No. Street Name Cell Phone
PUROK LAPU-LAPU
Subdivision Barangay Business (Direct Line)
WHITE BEACH
Municipality/City Province/State/Country Business (Trunk Line)
PAGADIAN CITY ZAMBOANGA DEL SUR, PHILIPPINES
ZIP Code Email Address
7016
PRESENT HOME ADDRESS
Unit/Room No., Floor Building Name Lot No., Block No., Phase No.
House No. Street Name Subdivision Barangay
PUROK LAPU-LAPU WHITE BEACH
Municipality/City Province/State/Country ZIP Code
PAGADIAN CITY ZAMBOANGA DEL SUR, PHILIPPINES 7016
PREFERRED MAILING ADDRESS PRESENT HOME ADDRESS
THIS FORM MAY BE REPRODUCED. NOT FOR SALE.
GENERATED BY: DURANO, IRVIN LLOYD P DATE/TIME: 07-jan-2026 [Link] System Version no. 3.2.2
HQP-PFF-039
(V10, 04/2023)
OFFICE CLERKS, GENERAL
OCCUPATION EMPLOYMENT STATUS TYPE OF WORK
CITY GOVERNMENT OF PAGADIAN
EMPLOYER/BUSINESS NAME COUNTRY OF ASSIGNMENT
Unit/Room No., Floor Building Name MONTHLY INCOME
Basic 0.00
Lot No., Block No., Phase No. House No. Street Name Allowances/Others
Total Mo. Income 0.00
Subdivision Barangay
PAGADIAN CITY ZAMBOANGA DEL SUR OFFICE ASSIGNMENT
Municipality/City Province
PHILIPPINES
State/Country(if abroad) ZIP Code DATE EMPLOYED
PREVIOUS EMPLOYMENT FROM DATE OF Pag-IBIG MEMBERSHIP
EMPLOYER/BUSINESS NAME OFFICE ASSIGNMENT
EMPLOYER/BUSINESS ADDRESS FROM TO
HEIRS
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME NO MIDDLE NAME RELATIONSHIP DATE OF BIRTH
[ ]
CERTIFICATION
I hereby certify that the information given, and all statements made herein are true and correct. Likewise, I hereby authorize Pag-IBIG Fund to collect record, organize, update/modify,
consult, use, consolidate, block, erase or destruct my personal data as part of my information. I hereby affirm my right to: (a) be informed; (b) object to processing; (c) access;
(d) rectify, suspend or withdraw my personal data; (e) damages; and (f) data portability pursuant to the provision of R.A. No. 10173 (Data Privacy Act of 2012).
_____________________________ ___________________
SIGNATURE OF INFORMANT DATE
FOR Pag-IBIG FUND USE ONLY
RECEIVED BY DATE
_________________________ ___________________ ________________
Signature over Printed Name Designation/Position Branch/Unit
DISCLAIMER
Membership registration with the Fund does not automatically qualify a Pag-IBIG member to avail of the Fund's various programs. A Pag-IBIG member must satisfy the eligibility
requirements and comply with the documentary requirements, which is subject to verification and approval.
GENERATED BY: DURANO, IRVIN LLOYD P DATE/TIME: 07-jan-2026 [Link] System Version no. 3.2.2