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Philippine Registry Form

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Place�
for Persons with Disability 2" x2"
Photo Here
REGISTRATION NUMBER: DATE:
LAST NAME: FIRST NAME: MIDDLE NAME:

TYPE OF DISABILITY (Please check only one} :

D Psychosocial Disability D Visual Disability D Orthopedic (Musculoskeletal)Disability
D Mental Disability D learning Disability Specific Ailment:
D Hearing Disability D Speech Impairment
ADDRESS
House No. and Street Barangay Municipality Province Region

TEL NOS:
DATE OF BIRTH (mm/dd/yyyy}
MOBILE NO.: I
AGE SEX (Please check one}:
EMAIL ADDRESS:
NATIONALITY:
OMale □ Female BLOOD TYPE:
CIVIL STATUS (Please check one}:
0 Single D Married Owidow/er D Seperated D Co-Habitation
EDUCATIONAL STATUS (Please check one}:
D Elementary D Elementary Undergraduate D High School
D High School Undergraduate Ocollege Ocollege Undergraduate
D Graduate D Post Graduate D Vocational C] None
EMPLOYMENT STATUS (Please check one}:
D Employed D Unemployed D Displaced Worker
D Resigned 0 Retired D Returning Overseas Filipino Work,er
NATURE OF EMPLOYER (Please check one if employed}:
D Private D Government
TYPE OF EMPLOYMENT (Please check one if employed}:
D Contractual D Permanent D Self-Employed D Seasonal
TYPE OF SKILL (Please check one}:
D Officials of Government and Special Interest SSS No.:
Organizations, Corporate Executives, Managers GSIS No.:
Managing Proprietors and Supervisors Phllhealth No.:
0 Professionals LJ PhilHealth Member
D Technicians and Associate Professionals D PhilHealth Member Dependent
D Farmers, Forestry Workers and Fishermen ORGANIZATIONAL INFORMATION: (OptJonal}
D Traders and Related Workers Organization
D Others Affiliated:
TAX CLAIMANT: Contact Person:
NAME: Office Address:

TIN NO.: Tel Nos.:

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Last Name First Name Middle Name
FATHER'S NAME :
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MOTHER'S NAME '
GUARDIAN'S NAME :
ACCOMPLISHED BY :
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PWD ID REQUIREMENTS :
IN CASE OF EMERGENCY :
Latest:
Contact Person :
1. MEDICAL Cl:RTIFICATE /
Contact Number/s ABSTRACT (for non-apparent
Department of Health
,:;
disability)
San Lazaro Compound, Sta. Cruz, Manila 2. BRGY. CLEARANCE / INDIGENCY
Republic of the Philippines t:ALUSLtF.A."i 3. 2 pcs. 2 X 2 ID PICTURIE
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4. SIGNATURE (use marker pen or
Local Government of Quezon City thumb mark on a piece of bond Paper)
Persons with Disability Affairs Office 5. AUTHORIZATIONI LETTER
Tel: 9884242 loc. 8123 (in absence of PWD)