Form No.

MIS-05-02

PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN

(Government Service Insurance System)
Financial Center, Roxas Boulevard, Pasay City

ID Picture
MEMBERSHIP INFORMATION SHEET (Taken within the
last 3 months)

PERSONAL DATA:

Name: PEREZ FREDERICK II PABLO

Last name First Name Middle Name
Sex: M Civil Status: SINGLE TIN: 61132617000000
Date of Birth: ### Place of Birth: SAN MANUEL, PANGASINAN
(Month/Day/Year) Town/District City/Province
Residence/Mailing Address:
6 QUIRINO ST. GUISET SUR SAN MANUEL PANGASINAN 2438
House, Apt. or Bldg No./St. Name Barangay or Barrio Town/City Province Zip Cod

EMPLOYMENT DATA:
Office: PANGASINAN STATE UNIVERSITY Date of Original Appointment: ____________________________
(Month/Day/Year)
Office Address:
ALVEAR ST. LINGAYEN PANGASINAN
No. Street Town/City Province

Position Title: INSTRUCTOR I Status of Appointment: CONTRACTUAL

Present Salary: ________________________Date of Effectivity of Present Salary: _______________________
(Month/Day/Year)
For DEPED Employees only: Division No.: ________ Station No.: ________ Employee No.: ____________

Home Tel. No.: _______________________________ Celphone No.: ___________________________________

Office Tel. No.: _______________________________ eMail Address: _____________________________________

Signature of Member

Attested:

MS. EUFROCINA L. ABBRUZZSE

Signature over Printed Name of
Personnel/Administrative Officer