Vous êtes sur la page 1sur 3

2X2 Formal Photo

MEMBERSHIP APPLICATION FORM


White background
Local Chapter: ___________________________________________
Course: ___________________ Year Level: _____ Section: __________

New Renewing JPIA No.: _____________________

Name: ______________________________________________________________________________
(Surname) (First Name) (Middle Name)
Current Address: _____________________________________________________________________
___________________________________________________________________________________
Permanent Address: __________________________________________________________________
___________________________________________________________________________________
E-mail Address: __________________________ Mobile No.: __________________________________
Birthdate (mm/dd/yy): _____________ Age: ______ Gender: ______ Nationality: ________________
Person to contact in case of emergency
Name: ____________________________ Relationship: ____________________
Contact No.: _________________________
Social Media Accounts:
Facebook: _____________________ Twitter: _____________________
Instagram: ____________________ Google +: ____________________

Three most significant involvements and leadership positions held (high school and college)

Leadership Positions/
Institution/ Organization/
No. Organization/ Program/ Duration
Program/Project
Event
1
2
3

Three most significant individual awards (high school and college)

Institution/ Organization/ Person who Name of the award /


No. Date received
conferred the award / recognition recognition
1
2
3
SELECT GROUP / COMMITTEE / TEAM THAT YOU WANT TO BECOME PART OF

JPIA Dance Troupe JPIA Artist Pool

JPIA Band JPIA Tutorials Guild

JPIA Chorale JPIA Quizzer’s Pool

JPIA Debate Team JPIA Academics Team

JPIA Elite JPIA Non Academics Team

JPIA Basketball Team JPIA Finance Team

JPIA Volleyball Team (Men) JPIA Editorial Board

JPIA Volleyball Team (Women) JPIA Multimedia Team

1. What do you expect from JPIA this federation year?

_____________________________________________________________________

_____________________________________________________________________

2. What event/s are you looking forward to attend to?

_____________________________________________________________________

_____________________________________________________________________

3. What can you suggest for JPIA to improve its events / activities for its members?

_____________________________________________________________________

____________________________________________________________________

4. What topics of seminars / workshop are relevant for you at your level?

_____________________________________________________________________

_____________________________________________________________________

I, hereby, state that the above information are true and correct, that I possess all the qualifications of being
a member of NFJPIA, NFJPIA-R3 and <Local Chapter> I will not violate any rules set for the organization
and that I dedicate myself into fulfilling the mission, vision, goals and objectives of NFJPIA, NFJPIA-R3
and <Local Chapter>.

_____________________________
Signature over printed name
DATA PRIVACY CONSENT AGREEMENT

NFJPIA, NFJPIA-R3 and <Local Chapter> recognize their responsibilities under the Republic Act No.
10173 (Act), also known as the Data Privacy Act of 2012, with respect to the data they collect, record,
organize, update, use, consolidate or destruct from our members.

The personal data obtained from this Membership Form is entered and stored by the Regional Vice
President for Membership within secured drive and will only be accessed by the authorized personnel of
NFJPIA, NFJPIA-R3 and <Local Chapter>.

NFJPIA, NFJPIA-R3 and <Local Chapter> have instituted appropriate organizational, technical and
physical security measures to ensure the protection of the members’ personal data.

Furthermore, the information collected and stored from our members shall only be used for the following
purposes:
1. Processing and reporting of documents related to the membership, (e.g., Membership Report).
2. Announcements / promotions of events, programs, and other activities organized by NFJPIA,
NFJPIA-R3 and <Local Chapter>.
3. Activities pertaining to establishing relations with sponsors and alumni.

NFJPIA, NFJPIA-R3 and <Local Chapter> shall not disclose the member’s personal information without
their consent and shall retain this information over a period of ten years for the effective implementation
and management of the organization.

MEMBER CONSENT

I have read the Data Privacy Statement of NFJPIA, NFJPIA-R3 and <Local Chapter> and express my
consent for NFJPIA, NFJPIA-R3 and <Local Chapter> to collect, record, organize, update or modify,
retrieve, consult, use, consolidate, block, erase or destruct my personal data as part of my information.

I hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my
personal data, and be indemnified in case of damages pursuant to the provisions of the Republic Act No.
10173 of the Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and
Regulations.

_____________________________ _________________
Signature over printed name Date