LAST NAME FIRST NAME

DISTRICT (for MUNICIPALITY (for SCHOOL ID SCHOOL SCHOOL ADDRESS

Elementary) Secondary) (Dela
Cruz) (Maria)

SAN MAXIMO, NATIVIDAD,

NATIVIDAD 101844 SAN MAXIMO ES PANGASINAN LACRO MANUEL
MIDDLE NAME EXTENSIO MOTHER PLACE OF BIRTH
N NAME CONTACT EMAIL ADDRESS TONGUE/ DATE OF BIRTH (Municipality and
(Sr., Jr., III) NUMBER ETHNICITY (mm/dd/yy) Province/City)
(Santos)

QUINAPONDAN,
PADERNOS Jr. 0907-140-9361 manuel.lacrojr001@deped.gov.ph WARAY 09/15/85 EASTERN SAMAR
 GENDER
PREFEREN
CE

(e.g.
Straight/Ci ARE YOU A ARE YOU A
SPOUSE'S NAME NUMBER
SEX RELIGIOUS sgender,Ga CIVIL HEIGHT WEIGHT BREADWIN SOLO (Name, MI, SPOUSE'S OF
AFFILIATION y, Lesbian, STATUS (cm) (kgs) NER ? PARENT ? Surname) OCCUPATION CHILDREN
(YES/NO) (YES/NO)
Bisexual,
etc.)

OPTIONA
L
ROMAN JAYE-ANN V.
Male Cisgender Married NO NO MAGSALIN-LACRO HOUSEWIFE 0
CATHOLIC 171 89
 For
Bachelor Are you
DATE OF GROSS NET SALARY District of
ORIGINAL Secondary HIGHEST willing to
YEARS IN STEP SALARY Designatio EDUCATIO undergo
APPOINTM THE PRESENT SALARY INCREMEN (Based on n/ ELIGIBILITY BACHELOR' Education, NAL GAD
ENT SERVICE POSITION GRADE T the Latest (Based on the Coordinato S DEGREE specify ATTAINME Training
(mm/dd/y Latest Payroll) your major
y) Payroll) rship of NT via online
this year?
specializati
on

MA
11/06/09 12.11 Teacher II 12 1 29,608.00 5000-10000 SDRRM LET BEED N/A Undergrad Yes
uate
 Do you Do you Other
IF YES, what are Are you a If YES, have a know your Do you If YES, Are you
physical undergoin
your priority GAD benefits specify
Person specify PWD ID have any health
topics you want to (Second Priority (Third Priority Topic) with your Card and physical your problems. g Executive
learn this CY 2021? Topic) Disability/i Disability/i issued by privileges health physical Checkup
as Person health every
(First Priority Topic) es (PWD)? es the with problems? problems. (Please year?
DSWD? Specify)
Disability?

DepEd Child Mental Health

Protection Policy Education Human Rights No No
 IF YES, do Do you IF YES, do Do you Have you
you have a know your you have a know your Are you ever /do School
Senior
Are you a privileges Are you a Single privileges struggling you suffer GAD
Senior Citizen and single Parent ID and with your from Coordinato
Citizen? Card benefits as parent? issued by benefits as mental mental r/ Data
issued by
the Senior the a Single health? health Encoder
Citizen? DSWD? Parent? disorder?
DSWD?

No No No No
NO