CS Form No.

211
Revised 2018

MEDICAL CERTIFICATE
(For Employment)

INSTRUCTIONS
a. This medical certificate should be accomplished by a licensed government physician.
b. Attach this certificate to original appointment, transfer and reemployment.
c. The results of the following pre-employment medical/physical/psychological
must be attached to this form:
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

FOR THE PROPOSED APPOINTEE

NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS

ADDRESS

AGE SEX CIVIL STATUS PROPOSED POSITION

FOR THE LICENSED GOVERNMENT PHYSICIAN

I hereby certify that I have reviewed and evaluated the attached examination results, personally examined the
above named individual and found him/her to be physically and medically FIT / UNFIT for employment.
SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE

AGENCY/Affiliation of Licensed Government Physician:

LICENSE NO. HEIGHT (M) WEIGHT (KG) BLOOD

Bare Foot Stripped TYPE

OFFICIAL DESIGNATION DATE EXAMINED

 HQP-PFF-049
(V07, 10/2020)
Pag-IBIG MID NUMBER
MEMBER’S CHANGE OF
INFORMATION FORM (MCIF) HOUSING ACCOUNT NUMBER (if applicable)

INSTRUCTIONS
1. This form shall be accomplished in one (1) copy.
2. Accomplish the applicable portions to be changed/corrected only. Indicate N/A if not applicable.
3. Print all entries in BLOCK/CAPITAL LETTERS.
4. Submit duly accomplished form together with required supporting documents to any Pag-IBIG Branch nearest you.
NOTE: Please submit photocopy of the documents depending on the information to be changed. The original or certified true copy of the said document shall be
presented for authentication.
CHECK THE APPROPRIATE BOX/BOXES AND ACCOMPLISH ONLY THE APPLICABLE PORTION/S TO BE CHANGED/UPDATED
Change of Membership Category Change of Marital Status Updating of Heirs
Change/Correction of Name Change of Address/Contact Details Others (Please specify)
Correction of Date of Birth Change of Employment Details _____________________
LAST NAME FIRST NAME NAME EXTENSION (e.g., Jr., II) MIDDLE NAME

1. CHANGE OF MEMBERSHIP CATEGORY

FROM TO

2. CHANGE/CORRECTION OF NAME (Last Name, First Name, Name Extension, Middle Name)
FROM TO

3. CORRECTION OF DATE OF BIRTH

FROM (mm/dd/yyyy) TO (mm/dd/yyyy)

4. CHANGE OF MARITAL STATUS

FROM TO

FOR MARRIED WOMEN

Use Husband’s Surname Use Maiden Name – Husband’s Surname Retain Maiden Name
SPOUSE Last Name First Name Name Extension Middle Name No Middle Name DATE OF BIRTH (mm/dd/yyyy)
(For Married Status)

5. CHANGE OF ADDRESS/CONTACT DETAILS (Please accomplish portions to be changed only)

PRESENT HOME ADDRESS (Indicate country code if abroad)
Unit/Room No. Floor Bldg. Name Lot No. Block No. Phase No. House No. Street Name Subdivision COUNTRY+AREA CODE TELEPHONE NUMBER

Home

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

Cellphone

PERMANENT HOME ADDRESS

Unit/Room No. Floor Bldg. Name Lot No. Block No. Phase No. House No. Street Name Subdivision Business (Direct Line)

Barangay Municipality/City Province/State/Country (if abroad) Zip Code Business (Trunk Line)

Email Address
PREFERRED MAILING ADDRESS
Present Home Address Permanent Home Address Employer/Business Address
6. CHANGE OF EMPLOYMENT DETAILS
EMPLOYER/BUSINESS NAME OCCUPATION

EMPLOYER/BUSINESS ADDRESS EMPLOYMENT STATUS

Unit/Room No. Floor Bldg. Name Lot No. Block No. Phase No. House No. Street Name Subdivision

Barangay Municipality/City Province/State/Country (if abroad) Zip Code DATE EMPLOYED (Month, Year)

7. UPDATING OF HEIRS (Please use separate sheet, if necessary)

LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME NO MIDDLE NAME RELATIONSHIP DATE OF BIRTH ADDITION/DELETION
(e.g. Jr., II) (Check if applicable only) (mm/dd/yyyy

8. OTHERS (Please specify)

FROM TO

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 over Printed Name of Member Date
THIS PORTION IS FOR Pag-IBIG USE ONLY
RECEIVED BY DATE APPROVED BY DATE

THIS FORM MAY BE REPRODUCED. NOT FOR SALE.

 HQP-PFF-049
(V07, 10/2020)

CHECKLIST OF REQUIREMENTS

MEMBER FILING THROUGH A REPRESENTATIVE

A. Change of Membership Category A. Change of Membership Category
 Member’s Change of Information Form (MCIF) (1 Original)  Member’s Change of Information Form (MCIF) (1 Original)
 Valid ID acceptable to the Fund (1 Photocopy)  Valid ID of both parties (1 Photocopy)
 Authorization Letter (1 Original)

B. Change/Correction of Name B. Change/Correction of Name

 For Change in name due to Marriage  For Change in name due to Marriage
- MCIF (1 Original) - MCIF (1 Original)
- Marriage Contract (1 Photocopy) - Marriage Contract (1 Photocopy)
- Valid ID acceptable to the Fund (1 Photocopy) - Valid ID of both parties (1 Photocopy)
- Authorization Letter (1 Original)

 For Change in name (for reason other than Marriage)  For Change in name (for reason other than Marriage)
- MCIF (1 Original) - MCIF (1 Original)
- Birth Certificate (1 Photocopy) - Birth Certificate (1 Photocopy))
- Court Order granting petition of change of name - Court Order granting petition of change of name
(1 Photocopy) (1 Photocopy)
- Valid ID acceptable to the Fund (1 Photocopy) - Valid ID of both parties (1 Photocopy)
- Authorization Letter (1 Original)

C. Correction of Date of Birth C. Correction of Date of Birth

 MCIF (1 Original)  MCIF (1 Original)
 Birth Certificate (1 Photocopy)  Birth Certificate (1 Photocopy))
 Valid ID acceptable to the Fund (1 Photocopy)  Valid ID of both parties (1 Photocopy)
 Authorization Letter (1 Original)

D. Change of Marital Status D. Change of Marital Status

 For Single to Married  For Single to Married
- MCIF (1 Original) - MCIF (1 Original)
- Marriage Contract (1 Photocopy) - Marriage Contract (1 Photocopy)
- Valid ID acceptable to the Fund (1 Photocopy) - Valid ID of both parties (1 Photocopy)
- Authorization Letter (1 Original)

 For Married to Single (legally married to reported spouse)  For Married to Single (legally married to reported spouse)
- MCIF (1 Original) - MCIF (1 Original)
- Court Order (1 Photocopy) - Court Order (1 Photocopy)
- Valid ID acceptable to the Fund (1 Photocopy) - Valid ID of both parties (1 Photocopy)
- Authorization Letter (1 Original)

 For Married to Single (due to erroneous encoding)  For Married to Single (due to erroneous encoding)
- MCIF (1 Original) - MCIF (1 Original)
- CENOMAR (1 Photocopy) - CENOMAR (1 Photocopy)
- Valid ID acceptable to the Fund (1 Photocopy) - Valid ID of both parties (1 Photocopy)
- Authorization Letter (1 Original)

 For Married to Widowed  For Married to Widowed

- MCIF (1 Original) - MCIF (1 Original)
- Death Certificate of the deceased spouse - Death Certificate of the deceased spouse (1 Photocopy)
(1 Photocopy) - Valid ID of both parties (1 Photocopy)
- Valid ID acceptable to the Fund (1 Photocopy) - Authorization Letter (1 Original)

E. Change of Address/Contact Details E. Change of Address/Contact Details

 MCIF (1 Original)  MCIF (1 Original)
 Valid ID acceptable to the Fund (1 Photocopy)  Valid ID of both parties (1 Photocopy)
 Authorization Letter (1 Original)

F. Change of Employment Details F. Change of Employment Details

 MCIF (1 Original)  MCIF (1 Original)
 Valid ID acceptable to the Fund (1 Photocopy)  Valid ID of both parties (1 Photocopy)
 Authorization Letter

G. Updating of Heirs G. Updating of Heirs

 MCIF (1 Original)  MCIF (1 Original)
 Valid ID acceptable to the Fund (1 Photocopy)  Valid ID of both parties (1 Photocopy)
 Authorization Letter (1 Original)

H. Correction of Place of Birth/Mother’s Maiden Name/Gender H. Correction of Place of Birth/Mother’s Maiden Name/Gender
(Due to erroneous encoding) (Due to erroneous encoding)
 MCIF (1 Original)  MCIF (1 Original)
 Birth Certificate (1 Photocopy)  Birth Certificate (1 Photocopy)
 Valid ID acceptable to the Fund (1 Photocopy)  Valid ID of both parties (1 Photocopy)
 Authorization Letter (1 Original)

NOTE: In all instances wherein photocopies are submitted, the original or certified true copy must be presented for authentication.