PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN

(Government Service Insurance System) 2x2

Financial Center, Roxas Boulevard, Pasay City ID Picture
(MEMBER)
MEMBERSHIP INFORMATION SHEET

2x2
ID Picture
(SPOUSE)

PERSONAL DATA:

Name: __________________________________________________________________________________________
Last name First Name Middle Name

Sex: ______________ Civil Status: ______________________ TIN: ______________________________

Date of Birth: _____________________ Place of Birth: ____________________________________________________

(Month/Day/Year) Town/District City/Province

Residence/Mailing Address:
_________________________________________________________________________________________
House, Apt. or Bldg No./St. Name Barangay or Barrio Town/City Province Zip Code

EMPLOYMENT DATA:

Office: _________________________________________ Date of Original Appointment: ____________________________

(Month/Day/Year)
Office Address:
________________________________________________________________________________________
No. Street Town/City Province

Position Title: __________________________________ Status of Appointment: ___________________________

Present Salary: _________________________ Date of Effectivity of Present Salary: __________________________

(Month/Day/Year)

For DEPED Employees only: Division No.: ____________ Station No.: ____________ Employee No.: _______________

Home Tel. No.: ________________________________ Celphone No.: ___________________________________

Office Tel. No.: ________________________________ eMail Address: _____________________________________

REQUIREMENTS FOR MEMBERSHIP:

: 2 Application for Membership

: NSO SECURITY PAPER
: Birth Certificate
Signature of Member : Marriage Contract
: SERVICE RECORD
Attested: : Copy of Appointment/Plantilla/Contract of Services
: Payslip/Cert. of Premium payment

ADDITIONAL REQUIREMENTS FOR ELECTIVE OFFICIAL:

: Oath of Office
: Certificate of Canvass
Signature over Printed Name of
Personnel/Administrative Officer — SERVICE RECORD ONLY FOR REINSURANCE
(W/ MATURED POLICY)
— PHOTOCOPY MUST BE CERTIFIED FROM ORIGINAL
COPY (ADMIN)/ORIGINAL MUST BE PRESENTED.
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