RESIDENCE ADDRESS: ~| E-MAIL ADD

DILG-NBOO-ISTMS BOIS Form 2013-1B

BARANGAY OFFICIAL'S INFORMATION SHEET

1X1
(APPOINTIVE OFFICIALS) ID Picture

REGION _ CITY/MUN
PROVINCE . BARANGAY

POSITION: Barangay Secretary Barangay Treasurer

NAME:
(Last) (First) (Middle) (Ext)

DATE OF BIRTH PLACE OF BIRTH

MM DD YYYY
SEX: Q
~^ MALE
MALE CIVIL STATUS: Q SINGLE Q WIDOW / ER
SEX:
QI FEMALE
FEMALE CH MARRIED Q SEPARATED
HIGHEST EDUCATIONAL ATTAINMENT: Q] ELEM QhIGHSCH Q] COLLEGE Q POSTGRAD
Please specify: | |Graduate I I Under Graduate

House No /Str
eet Name

CONTACT NUMBERS:
BGY. HALL TEL NO | | ] RES. TEL NO [_

CELLPHONE NO | | [
BENEFICIARIES:
NAME DATE OF BIRTH RELATIONSHIP
1.

2. .

3._

4._

5.-

I hereby certify that the above information are true and correct to the best of my knowledge.

Signature Over Printed Name Date Accomplished

Cer
tified by:

CD/CLGOO/MLGOO (Signature Over Printed Name) Date