4/1/2019 Philippine Registry for Persons with Disabilities

Retrieve Online Registration  

Philippine Registry Form for Persons With disability Place

Ver. 2.0 1" X 1"
1. PWD NUMBER: 2. DATE: Photo
here
3. LAST NAME: FIRST NAME: MIDDLE NAME:
DIAMZON CHRISTIAN DE LOS REYES
4. TYPE OF DISABILITY:
[ ✓ ]Psychosocial Disability [ ]Learning Disability [ ]Mental/Intellectual
[ ]Visual Disability [ ]Orthopedic(Muscoloskeletal) Disability
[ ]Hearing Disability [ ]Speech Impairment
5. CAUSE OF DISABLITY
[ ]Congenital/Inborn [ ✓ ]Illness [ ]Injury
6. ADDRESS:
House No. and Street Barangay City/Municipality Province Region
BLOCK 7B LOT 6 CELLINI ST. MILLE LUCE SUBD. SAN ROQUE (POB.) CITY OF ANTIPOLO RIZAL Region 4A
7. CONTACT DETAILS:
7a. TEL NOS.: 7b. MOBILE NO.: 7c. EMAIL ADDRESS.:
(02)661-87-01 (+63)915-924-2626 cddalert@gmail.com
8. DATE OF BIRTH (mm/dd/yyyy): 9. SEX 10. CIVIL SERVICE:
09/26/1981 [ ✓ ]Male [ ]Female [ ✓ ]Single [ ]Married
[ ]Wiodow/er [ ]Separated [ ]Co-habita on(Live-in)
11. EDUCATIONAL ATTAINMENT:
[ ]Elementary Undergraduate [ ]Elementary Graduate [ ]Highschool Undergraduate [ ]Highschool Graduate
[ ]College Undergraduate [ ]College Graduate [ ✓ ]Post Graduate [ ]Voca onal [ ]None
12. EMPLOYMENT STATUS:
[ ]Employed [ ✓ ]Unemployed
13. TYPE OF EMPLOYMENT(Please check one if employed):
[ ]Private [ ]Government
14. TYPE OF EMPLOYER (Please check one if employed):
[ ]Permanent [ ]Regular [ ]Contractual [ ]Casual [ ]Self-Employed [ ]Seasonal [ ]Emergency
15: OCCUPATION:(Please check one): 16. ID Reference No.
SSS No.: 33-7041769-2
[ ]Officials of Government and Special Interest
Organiza ons, Corporate Execu ves, GSIS No.:
Managers, Managing Proprietors and Pag-Ibig No.: 1020-0404-6377
Supervisors Philhealth: 19-089761939-7
[ ]Professionals
[ ]Technicians and Associate Professionals [ ✓ ]Philhealth Member
[ ]Clerks [ ]Philhealth Member Dependent
[ ]Service Workers and Shop and Market Sales 17. BLOODTYPE:
[ ]Farmers, Forestry Workers and Fishermen [ ]A+ [ ]A- [ ✓ ]B+ [ ]B-
[ ]Trades and Related Works [ ]AB+ [ ]AB- [ ]O+ [ ]O-
[ ]Plant and Machine Operators and Assemblers
[ ]Laborers 18. ORGANIZATION INFORMATION:
[ ]Unskilled Workers Organiza on Affiliated:
[ ]Not Applicable Contact Person:
[ ]Others, specify
Office Address:
Tel Nos.:
19. FAMILY BACKGROUND: Last Name First Name Middle Name
Father's Name: DIAMZON FLORIAN ZAPANTA
Mother's Name DE LOS REYES REBECCA DECANO
Guardian's Name DIAMZON CHRISTIE ANN DELOS REYES
20. ACCOMPLISHED BY: CHRISTIAN
20a.NAME OF REPORTING UNIT:
21. REGISTRATION NUMBER: 147684

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4/1/2019 Philippine Registry for Persons with Disabilities

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