LAV Forni No. 01
O
Republic of the Philippines
COMMISSION ON ELECTIONS
is Committee on Local Absentee Voting
MAY 9, 2016 NATIONAL AND LOCAL ELECTIONS
APP!
ATION TO AVAL
-AL ABSENTEE V'
1.PERSONAL DATA: (Please use the same name as appearing in your registration record.)
(a) Name: - - -
Garmame) Girst name) (Middle name)
(b) Sex: Male (remale
(c) Civil Status: [J single LD Married Widow/er
(4) Date of Birth: -
(@ Contact Numbers: Mobile:
Email address:
Place of Birth:
__HQ/Office Tel. No =
2. 1AM A REGISTERED VOTER OF;(Note: Please go to
comelec,gov.ph/2r=VoterRegistratinn /Registration: enifigation/presauct finder
for information on the following data.)
(0,
(Precinct No,/Barangay) (City/ Municipality) (Province)
(g) Voter's Registration Record Number (VRRN)
(h) Voter's Identification Number (VIN)
3. 1 WANT TO AVAIL OF LOCAL ABSENTEE VOTING BECAUSE I WILLBE ASSIGNED ON
ELECTION DAY TO PERFORM ELECTION DUTIES/COVER AND REPORT ON THE
\ CONDUCT OF ELECTIONS OUTSIDE THE PLACE WHERE I AM A REGISTERED VOTER
Please check the appropriate box:
{ L_] tama government official /employee
| Government Office _
| Position _
Place of Assignment
Name of Head of Office/Supervisor
(i) [Jama member of the PNP
Position /Rank.
Place of Assignment
Name of Station Head -
| 0
(Jt ama member of the AFP
Rank,
| Unit.
Serial Number =
Place of Assignment z as
Name of Commanding Officer
wo
[Cama member of the media
— | Position,
Place of Assignment
__ | Name of Head of Company.
« \s Thereby certify that the above declarations are true and correct.
SUBSCRIBED AND SWORN
2016 at
to
before
(Signature of applicant above printed name)
me this _ day of
Philippines.
(Signature above printed name)
Officer Authorized to Administer Oath