ParaiselslandForm Version2021.3 Samal TOURIST QR Code Application Form Reminders: 1. QR code application will take at least 24 hours to be approved by the LGU of Samal; 2. All guests are required to have their respective QR Code per person; 3. QR code is for single use only; 4. NO QR codes will be issued for kids below 6 years old; and 5. Send us back the accomplished application form along with all your gov't issued valid IDs w/ address. Day Tour: [¥ Overnight: # of Room/s: Reservation Date: from oi @ to wit & No. of Adults: 5 No. of Children (up to 12yrs old): __2 Arrival Time: _0* Entry Point: Private Terminal|~ Public Ferry |< EMAIL Address: _barcapatatingiug@ yahoo. com (Samal City LGU will send to this email the QR codes once approved) Complete Name: PACA une _—_@NGHRO. PATRLINGHUG Age: _ 24 First Middle (complete) ‘Sumame Gender: Fenanie Date of Birth: 021171992 _ Mobile #: 078 952 2185 Address: PHS, BLK W, W2TDL BI, ELEMITA HTS PARK VILLAS, CATILUAAAY GRANDE, DAVAO CITY St/PuroK/Sitio Barangay District city Complete Name: _oes ecian uinnenn ANGCAYA Age: _24 First Middle (complete) Surname Gender, mince Date of Birth: _2!/'5/'9®7_ Mobile #: 073 082 3724 Address: BOL BE, LOTIT, PHY AREAL ST, GREEN WEKOOWE GUBO., MUNTAL, ONVKO OY ‘St/Purok/Sitio Barangay District City Complete Name: _citoe_nueLin PATALINGHG Age: 8 First Middle (complete) ‘Sumame Gender: FOAL Date of Birth: ovlo7/2 Mobile #: 029 952 2/95 Address: PHS, GOKU, LOT 20% I, GLENITA HTS PRE VILLAL, CATALUNAN GRANOE , DAVAO CTY, ‘St/Purok/Sitio Barangay District City Complete Name: _ANGeto_pomuiaue WULARosA ‘Age: _" First Midalle (complete) ‘Sumame Gender: une Date of Birth: 4129127 _ Mobile #: _0922 082 374 Address: ADU, LOTIT, PHM, YARAL ST, GREEN ERDONE GUGD., WIMITAL, DwVAO CITY ‘St/Purok/Sitio Barangay District City “All quests must fill-up the application form.*Complete Name: Gender: Address: Complete Name: Gender Address: Complete Name: Gender: Address: Complete Name: Gender: Address: Complete Name: Gender: Address: Complete Name: Gender: Address: ParadiselslandForm Version2021.3 in RANMEIR—_ALCONTIN nous Age: _ 2 First ‘Middle (complete) ‘Surmame cus Date of Birth: osltei'944 Mobile #: 0927. 179 aes PUROK GACHO, PB. KAPUTIAN, IKLAND GARDEN COY OF SAMAL, St/Purok/Sitio Barangay District City JORMA MINE see rur0R ‘Age: _24 First ‘Middle (complete) ‘Sumame FeUNLe Date of Birth: 94l'@!1942 Mobile #; 024 179 waed TAROK CACRO, POD. KADUTIAM, YELANO GARCEN CIMT OF AMAL StPUroK/Sitio Barangay District city ELIANA GorRIA —_ THTOR temve poe First Middle (complete) ‘Surname “fevate Date of Birth: _'Is120 Mobile #: 2022 14 4904 PARK CACHO, POD. KApUnAN, ISLAND GARDEN CY OF CANAL St/Purok/Sitio Barangay District City Age: First ‘Middle (complete) ‘Surmame Date of Birth: Mobile #: St/Purok/Sitio Barangay District City Age: First ‘Middle (complete) ‘Sumame Date of Birth: Mobile #: St/Purok/Sitio Barangay District City Age: First ‘Sumame Mobile #: ‘St./Purok/Sitio Barangay District City “All quests must fll-up the application form.”