Republic of the Philippines

CIT Y SOCIAL WELFARE AND DEVELOPMENT OFFICE

Upper Session Road Extension, Baguio City
Tel. Nos. (07 4 ) 4 4 2 -7 893 /4 4 2 -3 84 2
E-m ail Address: cswdo_baguiocity @y ahoo.com .ph

APPLICATION FORM:
PERSON WITH DISABILITY (PWD) IDENTIFICATION CARD
REGISTRATION NO.:1411 DATE:
LAST NAME: FIRST NAME: MIDDLE NAME:

TYPE OF DISABILITY (Please check) CITY ADDRESS :

_____ VISUAL DISABILITY PROVINCIAL ADDRESS :

[ ] Total [ ] Partial
DATE OF BIRTH: PLACE OF BIRTH:
_____ COMMUNICATION DISABILITY
[ ] Hearing Impairment
[ ] Speech SEX (Please check): CONTACT NUMBER:
[ ] Male [ ] Female
_____ ORTHOPEDIC DISABILITY NATIONALITY: BLOOD TYPE:

_____ INTELLECTUAL DISABILITY CIVIL STATUS:

[ ] Single [ ] Married [ ] Legally Separated
_____ LEARNING DISABILITY
[ ] Widow/er [ ] Co-Habitation
_____ MENTAL DISABILITY EDUCATIONAL ATTAINMENT: (Please check one)
[ ] Elementary Graduate [ ] Elementary Undergraduate
_____ PSYCHOSOCIAL DISABILITY [ ] High School Graduate [ ] High School Undergraduate
CAUSE OF DISABILITY: [ ] College Graduate [ ] College Undergraduate
[ ] Inborn [ ] Post- Graduate [ ] Vocational Graduate
[ ] Illness/ Disease: __________________ [ ] Non-Formal Education
[ ] Injury Related SPECIAL LITERACY SKILLS :
[ ] Armed-Conflict [ ] Braille [ ] Sign Language
[ ] Accident [ ] Lip Reading [ ] Oral Communication
[ ] Environmental Cause Other skills: _______________________________________
EMPLOYMENT STATUS : (Please check one) NATURE OF EMPLOYER: (Please check one)
[ ] Employed [ ] Unemployed [ ] Displaced Worker [ ] Private [ ] Government
[ ] Resigned [ ] Retired [ ] Returning OFW
TYPE OF EMPLOYMENT : OCCUPATION:
[ ] Contractual [ ] Permanent [ ] Officials of Government and Special Interest Orgs., Executives, Managers,
[ ] Self- Employed [ ] Seasonal Supervisors, Managing Proprietors
[ ] Professionals [ ] Plant and Machine Operators
ID Reference No.
[ ] Technicians and Associate Professionals [ ] Laborers
SSS ID No. ____________________
[ ] Clerks [ ] Unskilled Workers
GSIS ID No. ___________________ [ ] Service Workers, Shops and Market Sales [ ] Not Applicable
Philhealth No. __________________
[ ] Farmers, Forestry Workers, Fishermen [ ] Others: _________________
[ ] Philhealth Member
[ ] Trades and Related Workers
[ ] Philhealth Dependent
ORGANIZATION AFFILIATION:
Organization Affiliated: ___________________________________________________________________
Contact Person: ______________________________Office Address: ______________________________
LAST NAME FIRST NAME MIDDLE NAME CONTACT NUMBER
FATHER’S NAME

MOTHER’S NAME
CONTACT PERSON IN
CASE OF EMERGENCY
I hereby certify that the above statements are true and correct to the Processed by:
best of my knowledge and belief. __________________________________
Noted by:
___________________________________
Signature/ Thumb mark of Applicant BETTY F. FANGASAN
City Social Welfare and Dev’t Officer
REQUIREMENTS:
 Duly Accomplishment Form
 Photocopy of Medical Certificate specifying the  2 copies 1x1 ID Picture
disability of applicant  Barangay Residency Certificate
NOTE: Chronic Illness is not a disab ility, rather a medical condition. To qualify for the 20% PWD discount, there should b e a dis ab ility
resulting from the chronic illness (For example, visual disab ility due to diab etes, orthopedic disab ility due to cancer).