NOT FOR SALE Kindly print 2 copies Processing Office : CENTRAL OFFICE

Appointment Date: January 17, 2014

Appointment Time: 10:00 AM

BALIK-MANGGAGAWA
INFORMATION SHEET

PERSONAL DATA

CRUZ CHARMAINE BRILLANTES

Last Name First Name Middle Name Name Ext. (e.g. Jr., III)
Passport No.:
Birthdate: 26/11/1983 Gender: Male X Female
DD / MM / YYYY Civil Status: X Single Widow/er
Place of Birth: QUEZON CITY Married Separated

Address in the Philippines: SAMUI 203 ROYAL PALM RESIDENCES, ACACIA ESTATES
Lot No. Block No. Phase No. House No. Street Name Subdivision
TAGUIG METRO MANILA 1632
City/Municipality Province ZIP Code

Telephone/Cellphone No.: 09999943971 Email Address: yunacruz2009@yahoo.com

SSS Number: Pag-IBIG RTN/MID: Eb9992327
Philhealth Number.:
Mothers Complete Maiden Name: ESTRELLA GUERRERO BRILLANTES
Name of Spouse (for married):

CONTRACT PARTICULARS OF OFW

Name of Company / Employer: KUWAIT AIRWAYS

Address of Employer: KAC SAFAT ROAD, SAFAT, KUWAIT CITY KUWAIT
Jobsite / Country of Destination: KUWAIT Tel.No./Fax No.: +96524348888
Position of OFW: CABIN CREW Contract Duration: 24 Months
Date of Return to the Philippines. : December 23, 2013 Salary / Currency: 600 / KUWAIT DINAR
Date of last deployment from the Philippines: September 29, 2012

LEGAL BENEFICIARIES / QUALIFIED DEPENDENTS

Children (20 years old and below) - Registered Birth Certificate; Non-Member Spouse - Registered Marriage Certificate; Parents (60 years old and above) - Senior
Citizens Card and Registered Birth Certificate of Member (OFW)

Complete Name Sex Relationship of OFW Date of Birth

to Dependent/s

JOHN BENEDICT CRUZ VILLAS MALE SON 03/30/2006

ESTRELLA BRILLANTES CRUZ FEMALE PARENT 01/10/1947

I hereby certify that the above statements are true and correct and that the above-named dependents have not been declared by my spouse/brother/sister.

CHARMAINE BRILLANTES CRUZ

TRANSACTION NUMBER: 138983992994 - 44949 Workers Signature Over Printed Name