GAWAD BIENVENIDO LUMBERA:

NCLA NATIONAL LITERARY CONTEST 2022

OFFICIAL ENTRY FORM
(This form must be notarized.)

TITLE OF ENTRY CATEGORY DIVISION

BASIC INFORMATION

Author’s Name :
Age :
Date of Birth :
Place of Birth :
Gender :
Civil Status :

CONTACT INFORMATION

Address :

Landline :
Mobile No. :
Email :

I am hereby entering the work listed above in the 2022 GAWAD BIENVENIDO LUMBERA: NCLA NATIONAL LITERARY CONTEST. I warrant that I
have solely written the work and that I am the absolute owner of the copyright(s) and other intellectual property rights pertaining to the work. I certify that
the work has not been published nor awarded and has not been submitted to any award-giving body this year, 2022.

Author’s Printed Name Author’s Signature

ACKNOWLEDGMENT
Republic of the Philippines)
) S.S.

BEFORE ME, this _____ day of _____________________, in ______________________, Philippines, personally appeared:

Name Government-issued Evidence of Identity Date/Place of Issue/Validity Period

known to me and to me known to be the same person/s who executed the foregoing instrument and who acknowledged to me that the same is his/her/their voluntary
and free act and deed.

Doc. No. _;
Page No. _;
Book No. _;
Series of 202_.