Republic of the Philippines

SOCIAL SECURITY SYSTEM 34-6976072-6

PERSONAL RECORD

Basic Information

Name of Applicant: MOLINA, MARIA LOURDES CASTRO

Date of Birth: 02/05/1993 (mm/dd/yyyy)

Sex: FEMALE

Marital Status: MARRIED

Nationality: FILIPINO

Religion:

Place of Birth: ASINGAN PANGASINAN PHILIPPINES

Home Address: PUROK CAPPIA DOMANPOT ASINGAN PANGASINAN 2439

Telephone No:

Mobile No: (0930) 735-0413

Email Address: molinam67@yahoo.com

Name of Father: CASTRO, LEONARDO ELLANO

Name of Mother: GAMEZ, FRANCISCA LUCENA

Beneficiary(ies)

Spouse: MOLINA, ERNESTO JR FERRER 03/06/1979

Child: MOLINA, LOURENCE CASTRO 12/31/2011

MOLINA, LITO CASTRO 09/01/2013

MOLINA, CHRISTIAN CASTRO 05/08/2015

Purpose of Application

Purpose: SELF EMPLOYED

Profession/Business: PERSONAL COLLECTION

Estimated Monthly Salary: (Php) 3,000.00

Applicant's Certification

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

TO BE FILLED OUT BY SSS

EVALUATED BY:

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Signature Over Printed Name Date Time Branch