PHILIPPINE COUNCIL FOR AGRICULTURE AND FISHERIES

PROVINCIAL AGRICULTURAL AND FISHERY COUNCIL

MEMBERSHIP PROFILE
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POSITION:
REGION:
MUNICIPALITY/PROVINCE:

A. PERSONAL INFORMATION
1 . Name:
(Last Name) (First Name) (Middle Name)
2 . Nick Name: Sex: Civil Status: Citizenship:
3 . Date of Birth: Place of Birth:
4 . Height (m): Weight (kg.): Blood Type: TIN No.:
5 . Residential Address:
6 . Telephone No.:
7 . Name of Spouse: Date of Birth:
8 . Name of Children:

9 . Highest Educational Attainment:

10 . Membership History in the AFC:
Position Period

11 . Training Attended ( in past 3 years):

12 . Title of Training Involvement Sponsoring Agency/Organization Date/Year

B. PRESENT INVOLVEMENT IN OTHER ORGANIZATIONS (Business, Civic, NGO, PO, Cooperative, Religious, Academ et

Name of Organizations Position

C. ORGANIZATIONAL INFORMATION
1 . Name of Organization Representative:
2 . Position:
3 . Address:
4 . Telephone No.: Fax No.: Website:

5 . Registration: SEC CDA Others Specify:

6 . Regsitration No. : Registry Date:

7 . Sector Represented ( pls. identify specific commodity sector/s)

Poultry & Fisheries & Others (Pls.

Food Staple Commercial Crops
Livestock Aquaculture specify)
Input Provider (specify type of
input)
Producer
Exporter
Marketing Distribution
Agrocultural Mechanization
Other Allied Services (specify)

8 . Geographical Scope of Operation: Regional Provincial Municipal/City Barangay

( Check appropriate box)
9 . Affiliations/Network:

10 . Involvement in Development Oriented Programs/Projects (in the past 5 Years)

Type of Involvement Sponsoring Agency/ Organization Date/Year

Signature over Printed Name

Date