+C.EsForm No. 5 Republic ofthe Philppines ‘COMMISSION OF ELECTIONS SYNCHRONIZED BARANGAY AND SANGGUNIANG KABATAAN ELECTIONS APPOINTMENT OF CHAIRPERSON /POLL CLERK/THIRD MEMBER BOARD OF ELECTION TELLERS ono pasay CITY, 2"? DisteicT-NCR Oey DOSE : i name; Hl AL BETO T: Spm Yh Seppe adress [Be ASOD SP NMI, ASI OY ETI wall Le ee SIR/ MADAM Youarenercty appoinea Te _CLWIMS rune nea of Election Tellers _Gatperen/ Pal aT NERDS in Precinct No. _S9S™ Barca JB} Gig Manipaiy of — Pay" —rornee of Eo MEA You may immediately assume office upon taking your oath as required by law. However, this appointment will be automatically cancelled and considered null and void if you are related to any candidate or to any member of the Board of Election Tellers of said precinct within the fourth civil degree of consanguinity or affinity. In such case, you shall not assume the duties of the office and shall immediately return this appointment to the Election Officer. Assumption to office notwithstanding this prohibition is punishable under the law. CE. Form No. 5-A PASAY CITY, ZN DISTRICT-NCR (City/Municipaty, Province) OATH OF BET CHAIRPERSON/POLL CLERK/THIRD MEMBER Lens AuteeMTD Fp! stemniy swear that 1 wil fauly perform the, duties of gis toe Faas tie nee Ie tae ee a ea re ea names Sabrent ee wa provice 1 the bl of my ine aed ety, without nyoting any peor, Se yn a ee i are den cape ey ls auy coats) emotes. sRu that I voluntanly impose upon myself this obligation without mental reservation oF purpose sFevasion,7"SP HELP ME: Gop! Ge pie Over Prd Name) LEER EA len 20 (Dat set, SUBSCRIBED AND SWORN to before me this ‘Administering Officer BET Chairperson/Co-Member Registered Voter of the Precinet PREPARED IN TRIPLICATE: The original copy shall be kept by the appointee; the second copy shall be given to the City/Municipal Election Officer; and the third copy shall be sent to the City/Municipat Treasurer Scanned with CamScanneray, Republic of the Pilppines DEPARTMENT OF TRANSPORTATION LAND TRANSPORTATION OFFICE LEVEL 1 EASTLANE ROBINSON'S GALLERIA ‘ORTIGAS CENTER QUEZON CITY Field Ofico: DLRG ROBINSON'S GALLERIA TIN: ____000865491001 Office Code: 1338 Date: _ 09/04/2023 10:59 AM ieNscsiae © 1338-000000044153 RECEIVED FROM (Last Name, First Name Middle Name) ‘SAMSON, LUIS ALBERTO FRANCIA ADDRESS (No. Strest, Barangay, Municipality, Zip Code, Province) 476 Ascano St, Barangay 176, Pasay City, 1300, Metro Manila, Fourth District “TWN (Tax Identification Number) TO Client ID/ LTO BUSINESS 1D 23-830831-8895897 Gael Uc. No: NOI-16-018885 | Medical Exam | Schedule 1: JULY 02,2027 to AUGUST 31,2027, \ Schedule 2: JULY 02,2030 to AUGUST | 31,20: [ ssaction: TX-DLS-20230904-133397 - | License Fee. ‘PHP a i (ets gn j } RENEWAL WITH VALID. Ne _Ticense,10-YEARS LICENSE | Seasstesion Be tance ee —— | ‘TOTAL AMOUNT PAID: PHP: 585,00 ‘AMOUNT IN WORDS: FIVE HUNDRED EIGHTY-FIVE PESOS MODE OF PAYMENT: Cash Locarion: Dre Robinson's Galeria Mandaluyong CASHIER: [Maria Angeline Louise Blaza POS MACHINE: DLROROSINSON GALLERIA- CASHIER Thic ga system generated Ofidal Recelpl, No Signatures needed. EAT Page t of Scanned with CamScannerFOR INQUIRIES YOU CAN REACH LTO DLRO ROBINSONS GALLERIA THROUGH: Facebook Messenger Account: LTO Robinsons Galleria License Renewal Office Landline: 8632-1703 Email Address: 1338dlrorobgalleria@gmail.com Scanned with CamScanner