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WAP
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Middle Name
*
Your answer
Ext
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Civil Status
*
Your answer
Status of Membership
*
Active
Inactive
Name of Claimant (Last Name)
*
Your answer
First Name
*
Your answer
Middle Name
*
Your answer
Ext
Your answer
Relationship to OFW
*
Your answer
Claimant's Contact Number
*
Your answer
Claimant's Address
*
Your answer
DOCUMENTS SUBMITTED
*
2 pcs 1x1 ID PhotoValid Government issued ID of designated
Passport of OFW and/ or Seaman's book (biopage)by the OFW
Latest Departure and Arrival stamps Authorization Letter
Latest Embarkation and Disembarkation stamps
Required
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