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