Form No. MIS-05-02

PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN(Government Service Insurance System)Financial Center, Roxas Boulevard, Pasay City

MEMBERSHIP INFORMATION SHEET

PERSONAL DATA:

Name: ___________________________________________________________________________________Last name First Name Middle Name

Sex: ______________ Civil Status: ______________________ TIN: ______________________________

Date of Birth: _________________ Place of Birth: _______________________________________________ (Month/Day/Year) Town/District City/Province

Residence/Mailing Address:

_________________________________________________________________________________________House, Apt. or Bldg No./St. Name Barangay or Barrio Town/City Province Zip Code

EMPLOYMENT DATA:

Office: ________________________________________Date of Original Appointment: ____________________________ (Month/Day/Year)

Office Address:

________________________________________________________________________________________No. Street Town/City Province

Position Title: __________________________________ Status of Appointment: __________________________

Present Salary: _________________________Date of Effectivity of Present Salary: _______________________ (Month/Day/Year)

Home Tel. No.: ________________________________ Celphone No.: ___________________________________

Office Tel. No.: ________________________________ eMail Address: _____________________________________

Signature of Member

Attested:

Signature over Printed Name of Personnel/Administrative Officer

For DEPED Employees only: Division No.: ________ Station No.: ________ Employee No.: ____________

ID Picture(Taken within the

last 3 months)

Name: ___________________________________________________________________________________

TIN: ______________________________

Place of Birth: _______________________________________________

_________________________________________________________________________________________

Date of Original Appointment: ____________________________

________________________________________________________________________________________

Status of Appointment: __________________________

Date of Effectivity of Present Salary: _______________________

Celphone No.: ___________________________________

eMail Address: _____________________________________

Division No.: ________ Station No.: ________ Employee No.: ____________