New Mutual Aid System Form

NMAS Application Form

New Mutual Aid System
CONSENT STATEMENT

By supplying your personal and sensitive information with the Philippine Public School Teachers Association (hereinafter referred as “PPSTA“ or the “company”) in this digital platform in the process of applying for and/or availing of insurance plans, loans, benefit claims and engaging the company for any other business transaction in accordance to its legitimate purpose as a mutual benefit association, you hereby consent to the processing, sharing, and/or transferring of your personal data relating to your account/s to PPSTA, its service providers or third parties/entities having authority or right and need to such disclosure of information including regulatory agencies, governmental or otherwise, in order to enable the company to service your account/s and needs, to provide all existing features and future enhancements thereto, and to avail other products, services, facilities, and channels available to you as member of the association. You likewise agree to hold PPSTA, and third party service providers free and harmless from any liability arising from or in connection with the consent herein given.

This consent statement is in compliance to the Data Privacy Act of 2012 and its implementing rules and regulations. For further clarification and guidelines of your Privacy Rights, you may refer to the our PPSTA Privacy Policy.
REQUIREMENTS

1. Photocopy of Latest Payslip
2. Permanent Appointment/ Latest Service Record
3. Photocopy of at least two (2) valid ID's

Click the button below and upload all files
Products and Services Information
Family Name*
First Name*
Middle Name*
Date

MonthDayYear
Date
House no. Street Name Barangay
Region
Division
Station
Employee number
Municipality/City,*
Province*
Zipcode*
Civil Status*
Sex*
Date of Birth:(mm dd yyyy)*

MonthDayYear
Date
Age*
Name of School*
Religion*
School Address*
Number, street, Barangay
School Address
Municipality/City, Province
Mobile No*
Landline No.
PermanentProvisional
DepEd Email Address*

Confirmation Emailjohndoe@deped.gov.ph
Regional Payroll System UnitDirectLocal(H. School/College/University)
MonthlyQuarterlyAnnually
BENEFICIARIES - Provide additional sheet/s if necessary- must be certified correct and signed by the member himself/herself) (Surname,Middle Name)Date of Birth(mm-dd-yyy)
Beneficiary 1
Date of Birth

MonthDayYear
Date
Relation
Share %
(if equal sharing just type 00)
irrevocable
Beneficiary 2
Date of Birth

MonthDayYear
Date
Relation
Share %
(if equal sharing just type 00)
irrevocable
Beneficiary 3
Date of Birth

MonthDayYear
Date
Relation
Share %
(if equal sharing just type 00)
irrevocable
Beneficiary 4
Date of Birth

MonthDayYear
Date
Relation
Share %
(if equal sharing just type 00)
irrevocable
HEALTH DECLARATION, CERTIFICATION, VENUE OF ACTION AND RECOMMENDATION
YESNO
YESNO
YESNO
1. Are you in good health and free from physical impairment, any deformity or disease? 2.During the last five (5) years, have you been hospitalized, or consulted or been treated by a physician for any reason? 3. Have you been treated for or been advised that you had any of the following: Heart, Lungs, Nervous or Kidney Disorder, High Blood Pressure, Cancer, Tumor or Diabetes?

I hereby certify that the above information are true and correct. I further cerfity that I have read and understand all rules and regulations pertaining to the New Mutual Aid System (NMAS) , and I abide fully by the terms of the same without any reservation. I hereby agree that all actions relating therewith shall be brought exclusively before the Regional Trial Court of Quezon City.
Customary Signature over Printed Name of Applicant (make sure to click the upload button after you select picture)
Two speciment signature of Applicant: (make sure to click the upload button after you select picture)
Two speciment signature of Applicant: (make sure to click the upload button after you select picture)
Date

MonthDayYear
Date
Personal Health Declaration form/ Latest Medical CertificatePhotocopy of Latest PayslipPermanent Appointment/ Latest Service RecordPhotocopy of at least two (2) valid ID's
HEALTH DECLARATION
Name*
Age*
Position / Division / Office*
Amount of Insurance Plan
Date of Birth

MonthDayYear
Date
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
Done at*
This*
Day of*
20*
Present weight in pounds?
Present height in feet and inches?
THROUGH THE DEPED AUTOMATIC PAYROLL DEDUCTION SYSTEM (APDS)
I hereby authorize DepEd to deduct monthly from my salary, through the DepEd APDS, the sum of PESOS: beginning on and ending on

) as premium/contribution, and to remit the same to Philippine Public School Teachers Association (PPSTA)in

consideration of the insurance policy/membership/other allowed obligation, more specifically described as 0044A. In case my premium contribution is not deducted from the payroll, regardless of the reason, I also authorize DepEd to automatically adjust the termination period in my pay slip by one (1) month for every month of delay of its deduction. I fully understand that no lapses of payment shall be made by the Accredited Entity for this purpose, thus, the corresponding benefit as contracted shall be available in case of need.

The authorization is VALID AND BINDING within the aforementioned period., unless the authorization is otherwise revoked. Morever, I agree that deductions that will reduce my monthly net take-home pay to lower than what is allowed under the law shall not be accommodated in the APDS.
Sum of PESOS
Peso in Number
Beginning On

MonthDayYear
Date
Ending On

MonthDayYear
Date
Employee No
Station Code
Division Code
Region
Date

MonthDayYear
Date
Recommending Officer
Approving Officer
Date

MonthDayYear
Date
SOLICITOR'S HONORARIUM
Input the Name of Solicitor
• Please click “Preview and Download PDF” button below to download the encoded application form.
• Open the form in any PDF Editor
• Attach your PNPKI Digital Signature
• Save Changes Made
• Upload the Accomplished Application Form
Upload Photo (Applicant 1x1) (make sure to click the upload button after you select picture)*
UPLOAD these: • Final Application Form in PDF Duly-signed Using PNPKI • Selfie Photo While Holding the Duly-Accomplished Membership Application Form
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Upload File Requirements*

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Should be Empty:

NMAS Application Form

HEALTH DECLARATION, CERTIFICATION, VENUE OF ACTION AND RECOMMENDATION

HEALTH DECLARATION

THROUGH THE DEPED AUTOMATIC PAYROLL DEDUCTION SYSTEM (APDS)

UPLOAD these: • Final Application Form in PDF Duly-signed Using PNPKI • Selfie Photo While Holding the Duly-Accomplished Membership Application Form