Republic of the Philippines

COMMISSION ON ELECTIONS
Office of the Election Officer
Alicia, Isabela
By filling out this form, you clearly indicate your DESIRE and WILLINGNESS to serve in the forthcoming December 05,
2022, Barangay and Sangguniang Kabataan Elections.

PERSONAL DATA
NAME:
SURNAME FIRST NAME MIDDLE NAME
RESIDENTIAL ADDRESS:
DATE OF BIRTH: AGE: SEX:
ACTIVE CELLPHONE NOS.: EMAIL ADD:
TIN NO:

EMPLOYMENT DATA
NAME OF SCHOOL:
CSCHOOL ADDRESS:
POSITION: NATURE OF EMPLOYMENT:
Are you related by any means to any candidate for any position within the 3rd civil degree by Consanguinity or affinity in the
municipality of Alicia, Isabela particularly in your Barangay this coming December 05, 2022 Barangay and Sangguniang Kabataan
Elections?

If yes, kindly enumerate the names:

NAMES POSITION RELATIONSHIP
BY CONSANGUITY BY AFFINITY
BY CONSANGUITY BY AFFINITY

WHAT POSITION DO YOU SERVE AS AN ELECTORAL BOARD MEMBER?

PREFERRED BARANGAY TO SERVE:
2ND OPTION IN CASE OF DISQUALIFICATION:

I hereby declare under oath that the above answers are true and correct.

SIGNATURE OVER PRINTED NAME OF APPLICANTS

TO BE FILLED UP BY COMELEC EMPLOYEES:
REGISTRATION RECORD
PRECINCT NO. BARANGAY MUNICIPALITY PROVINCE

ASSIGNMENT BARANGAY VOTING CENTER

ROMMEL B. GERONIMO
Election Officer III