BALIK-MANGGAGAWA INFORMATION SHEET

Appointment Date: January 05, 2016 09:00 AM

Processing Site: Region 1 (La Union)

PERSONAL DATA

NAVARRETE HERWIN MENDOZA

Last Name First Name Name Ext. (e.g. Jr.,III) Middle Name
EB5278573 July 21, 1985 Balaoan MALE MARRIED
Passport Birth Date Birth Place Sex Civil Status
Purok 3 Paraoir Balaoan LA UNION
Home Address in the Philippines
0119118728
SSS Pag-IBIG RTN/MID

09155126594 herwin.navarrete2013@yahoo.com
Telephone/Cellphone No. E-mail Address
Mother's Full Maiden Name:
Mendoza Crispula Tadije
Last Name First Name Middle Name
Name of Spouse (If married)
Navarrete Marnida Apilado
Last Name First Name Middle Name

CONTRACT PARTICULARS OF OFW

Ras Al Khaimah Cement Company

Name of Company/Employer
Khor Khwair Ras Al Khaimah United Arab Emirates UNITED ARAB EMIRATES
Address of Employer Country
+971072660111 / www.rakcc.ae/en 6800.00 AED
Tel. No./Fax No./E-Mail Address Salary / Currency

Central Control Room Operator 24 months

Position Contract Duration
December 27, 2014 December 01, 2015
Last Deployment Date Last Arrival Date

LEGAL BENEFICIARIES / QUALIFIED DEPENDENTS

Children (20 years old and below) - Registered Birth Certificate; Non-Member Spouse - Registered Marriage Certificate; Parents (60 years old and above) -
Senior Citizens Card and Registered Birth Certificate of Member (OFW)

Complete Name Sex Relationship of OFW to Dependent/s Date of Birth

Marnida Apilado Navarrete FEMALE WIFE November 01, 1988
Kashmir Ellineth Apilado Navarrete FEMALE DAUGHTER July 08, 2013
 LEGAL BENEFICIARIES / QUALIFIED DEPENDENTS
Khalen Drake Ezekiel Apilado Navarrete MALE SON August 08, 2015

I hereby certify that the above statements are true and correct and that the above-named dependents have not been declared by my spouse / brother/sister.

Control Number: N163739621

Worker's Signature Over Printed Name