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Republic of the Philippines

SOCIAL SECURITY SYSTEM 34-8586285-7


PERSONAL RECORD

Basic Information

Name of Applicant: BALINDONG, ABDULLATIP MANGELEN

Date of Birth: 08/26/1991 (mm/dd/yyyy)

Gender: MALE

Marital Status: SINGLE

Nationality: FILIPINO

Religion: ISLAM

Place of Birth: CITY OF PASIG METRO MANILA PHILIPPINES

Home Address: BANGKAL CITY OF MAKATI METRO MANILA 1233

Telephone No:

Mobile No: (0929) 444-4499

Email Address: pstarrr206@gmail.com

Name of Father: BALINDONG, AMER DATU

Name of Mother: MANGELEN, LILY MANGURUN

Beneficiary(ies)

Purpose of Application

Purpose: SELF EMPLOYED

Profession/Business: BUSINESSMAN

Estimated Monthly Salary: (Php) 5,000.00

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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