ANNEX "A" (FOR RECOMMENDATORY PURPOSES ONLY)

CERTIFIED LIST OF PUBLIC SCHOOL TEACHERS WHO ARE WILLING, AVAILABLE AND QUALIFIED TO SERVE AS MEMBERS OF THE
ELECTORAL BOARDS (EBs) for the 30 OCTOBER 2023 BARANGAY AND SANGGUNIANG KABATAAN ELECTIONS (BSKE)
* All fields are required to fill in.
Served in the
WILLING,
previous elections
AVAILABLE AND SIGNATURE OF THE APPLICANT (The
FULL NAME (LAST Name, MIDDLE Name; if female and QUALIFIED to Registered Voter as BET/BEI/EB (if Contact Number or signature is an attestation to the
married, their complete MAIDEN Names) Position/Designation School of Assignment become a Member with (YES/NO)
ACTIVE Status applicable, indicate Mobile/Cellphone Number
the position held
TIN (for tax purpose) truthfulness of all the facts indicated in
of the Electoral and election this Certificate)
Board (YES/NO)
year/s) (YES/NO)

Yes, Chairperson
Dela Cruz, Juana Garcia Teacher 1 North 1 ES YES YES 2018 BSKE
Yes, Chairperson
Dela Cruz-Rosales, Juana Garcia (married) Head Teacher 1 North 2 ES YES YES 2018 BSKE; Poll
Clerk 2016 NLE

I hereby certify that the foregoing public school teachers are qualified, willing, and available to serve as Members of the Electoral Boards for the October 30, 2023 Barangay and Sangguniang Kabataan
Elections (BSKE).

(Name and Signature)

DepEd Official's Designation
Subscribed and Sworn to me this ___________ day of ______________, 2023; Affiant exhibiting to me his/her competent evidence of identity: ______________________________________.

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 ATTY. ANA MEI S. BARBACENA
Election Officer IV

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