Republic of the Philippines Office of the President OPTICAL MEDIA BOARD 4# 35 Scout Limbaga Street, Barangay Laging Handa, Quezon City OMB DEPUTY AGENT APPLICATION FORM PERSONAL INFORMATION Name: (Cast Name) (First Name) (Middle Name) Address: ‘Contact Number: Civil Status: Date of Birth: Place of Birth: EDUCATIONAL BACKGROUND Elementary: Year: High School: Year. College : Year: Post Graduate: Year. Others : Year: EMPLOYMENT BACKGROUND Occupation —: Rank/Designation: Office Address : Contact Number/s : CRIMINAL RECORD Have you ever been administratively/criminally charged? _yes_no If YES, give details: Do you have an existing administratively/criminally cases? yes__n0 (CHARACTER REFERENCES 1. Name 7 Address Contact Number/s: 2. Name : Address: Contact Number/s: 3, Name : Address: Contact Number/s: RECOMMENDED BY: I hereby certify that the above stated information are true and correct to the best of my knowledge, and any ‘misrepresentation on any information given herein shall cause the immediate cancellation hereof. Signature of Applicant 2 pes. Colored Photo (1x1) Right Thumbmark Application Status: