ALLIED CARE EXPERTS (ACE) MEDICAL CENTER–GENSAN, INC.

Barangay Lagao, General Santos City

(083) 553-3595 / 0917-147-1905 / 0942-484-1238 PICT
acemc.gensan@yahoo.com I acemedicalcentergensan@gmail.com

SHAREHOLDERS PERSONAL DATA SHEET

Name: ____________________________________________________________________
Last First Middle
Age: ______

Sex: Male [Type

Female
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Status: Single
[Type Married
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[Type Widow
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Date of Birth: ____________________

Place of Birth: __________________________________

Present Address: ____________________________________________________

Lot/Block Street Barangay
____________________________________________________
Town/City Province Zip Code

Provincial Address: __________________________________________________

Lot/Block Street Barangay
_________________________________________________
Town/City Province Zip Code

Contact Nos. Mobile: ______________ Home: ________________ Office/Clinic: ___________

Email Address: _________________________________________
Educational Attainment: ___________________________________________
Present Occupation: ___________________________________________
Employer: ______________________________________________________

Office/Business Address: __________________________________________

PRC # ________________T.I.N. ________________ S.S.S. ______________PHIC _____________

Name of Spouse: ________________________________________________

Date of Birth: ________________ Age: ______ Occupation: ______________

Parents’ Name: Age: Date of Birth:

_____________________________ ________ _____________________
_____________________________ ________ _____________________

Children’s Name: Age: Date of Birth:

_____________________________ ________ _____________________
_____________________________ ________ _____________________
_____________________________ ________ _____________________
_____________________________ ________ _____________________
_____________________________ ________ _____________________

This is to signify that the information given is true and correct.

_________________________________ ___________ ________________

Signature Over Printed Name & Date Heidie Q. Ombao-Investor Relations Officer