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Republic of the Philippines

SOCIAL SECURITY SYSTEM 34-7402290-9


PERSONAL RECORD

Basic Information

Name of Applicant: DELA PEÑA, JOHN KENNETH PURCIA

Date of Birth: 06/25/2000 (mm/dd/yyyy)

Gender: MALE

Marital Status: SINGLE

Nationality: FILIPINO

Religion: ROMAN CATHOLIC

Place of Birth: TRECE MARTIRES CITY (CAPITAL) CAVITE PHILIPPINES

Home Address: BLK 12 LOT 4 BARANGAY 1 POBLACION (AREA I) GEN. MARIANO ALVAREZ CAVITE 4117

Telephone No:

Mobile No: (0930) 952-0416

Email Address: lingkod21@gmail.com

Name of Father: DELA PEÑA, MICHELLE CORDETA

Name of Mother: PURCIA, CATHERINE BONDAD

Beneficiary(ies)

Purpose of Application

Purpose: FOR EMPLOYMENT

Applicant's Certification

____________________________________ __________________
Signature Over Printed Name Date LEFT THUMB MARK RIGHT THUMB MARK

TO BE FILLED OUT BY SSS


EVALUATED BY:

___________________________________ ______________________ ______________________ ______________________


Signature Over Printed Name Date Time Branch

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