TO : All Members, Philippine Institute of Certified Public Accountants, Inc.

FROM : Board of Directors

Data Privacy Officer

DATE : July 11, 2018

SUBJECT: Membership Date Base (in relation to Data Privacy Act of 2012)

The BOD and the newly appointed DPO has the honor to inform the general membership that the
Philippine Institute of Certified Public Accountants, Inc. (PICPA) National Office is updating its members
data base and in this regard we want your written consent on the below listed concerns, to wit:

1. Give consent to PICPA to communicate with each member through emails, mobile and landline
phones.
Yes No
Comment

2. To allow PICPA to make, and issue member’s identification card containing their name,
picture, PRC ID No. and sectoral information
Yes No
Comment

3. To allow PICPA and its authorized IT provider, to process and include in the member’s
database the necessary information of member.
Yes No
Comment

To maintain privacy of each member, the PICPA and the IT officer-in-charge will issue a
“Non-Disclosure Agreement”.

Attached is the Form which contain the information which you are allowing PICPA to be included
in the members’ database.

For the Board of Directors:

MA. ASUNCION GOLEZ

President

CONFORME:

Signature over Printed Name

PICPA Member
 Philippine Institute of Certified Public Accountants – Metro Manila Region
G/F PICPA Building, 700 Shaw Blvd., Mandaluyong City
Tel. Nos.: 725-3337 | 723-6313 & Fax Nos.: 723-6314 | 723-8760
eMail: membership@picpammr.org | Website: www.picpammr.org

[PLEASE PROVIDE CORRECT AND CURRENT INFORMATION]

PERSONAL Date:
CPA/PRC No: PRC Registered Date: Sex: [ ]Male [ ] Female
NAME:
Last First Middle Mother Maiden Name
Birthday: Civil Status: [ ] Single [ ] Married [ ] Widow [ ] Separated Spouse Name:
Tel./Fax Nos.: Mobile No.: eMail:

MEMBERSHIP AFFILIATION
Region: Sector: [ ] Commerce & Industry [ ] Education
Chapter: [ ] Public Practice [ ] Government
( to be determined based on place of work or permanent residence)
CHAPTER CLASSIFICATION
0111-NORTHERN CHAPTER [ ] 0112-WESTERN CHAPTER [ ] 0113-EASTERN CHAPTER [ ] 0114-SOUTHERN CHAPTER [ ]
Caloocan City | Malabon City | Mandaluyong City | Manila | Marikina City | Pasig City | Las Piñas City | Muntinlupa City | Makati City |
Navotas City | Valenzuela City San Juan City Quezon City Parañaque City | Pasay City | Taguig City | Pateros
Type of Member: [ ] Regular [ ] Sustaining Life Member (SLM) [ ] Honorary Life Member (HLM)

WORK INFORMATION
Company Name & Address:

Position: Tel./Fax Nos: Company eMail:

HOME INFORMATION
Home Address:

Preferred Mailing Address: [ ] Office/Business [ ] Home

I HEREBY CERTIFY that the above information are true and correct to the best of my personal knowledge and belief. I further certify that the above information
were given as my voluntary act and deed. Furthermore I am giving PICPA my full consent to include the above information in the PICPA member’s database and to update
the same from time to time without further asking my written consent.

The above data includes sensitive personal information that need written consent of the data subject, under the Data Privacy Act of 2012.

PICTURE SIGNATURE