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PADRE BURGOS ELEMENTARY & SECONDARY TEACHERS

AND EMPLOYEES’ ASSOCIATION
District of Padre Burgos
Padre Burgos, Quezon Province

MEMBER’S INFORMATION
DATE OF MEMBERSHIP _________________________________
1x1
PERSONAL DATA latest photo
LAST NAME FIRST NAME MIDDLE NAME EXT. NAME
Member’s Name

Birthdate (mm/dd/yyyy) Gender Civil Status Religious Affiliation

Height (cm) □ MALE □ FEMALE □ Single □ Married

Weight (lbs) □ LGBTQIA+ □ Widow/er □ Legally Separated Blood Type

Birthplace (City / Municipality / Prov. / Country) Highest Educational Attainment (Course)

Last School Attended

Name of Spouse: Occupation

Birthdate: Contact Information:

ADDRESS AND CONTACT DETAIL

Unit / Rm. No. Lot No. Phase No. House No. Street

Subdivision Brgy. Municipality Province Zip Code

Email Address  __________________________________ Tel. No.  ___________________ Cellphone No. _______________________

TIN GSIS No.

Philhealth No. Pag-Ibig No.
Employee No.

EMPLOYMENT / OCCUPATION
Employers Division District Station Name (ID)

Occupation Employment Status Date Hired

FAMILY MEMBER
Remarks
Parents Name Age Birthdate (living / deceased)
Claimed Unclaimed
Father □ □
Mother □ □
Immediate Family Remarks
Member
Name Age Birthdate (living / deceased) Claimed Unclaimed
Legal Spouse □ □
1. □ □
Children 2. □ □
3. □ □
1. □ □
Siblings 2. □ □
3. □ □
Grandmother □ □
Grandfather □ □
APPROVED BENEFEC IARIES
RELATIONSHIP Name Age Birthdate Claimed Unclaimed
1. □ □
2. □ □
3. □ □

Received By: __________________________________________ Verified by: __________________________________

Encoded by: ___________________________________________ Approved by: ________________________________
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MEMBERSHIP & SUBSCRIPTION OF AGREEMENT

I, __________________________________________ a resident of ________________________________________________

agree to be a member of PBESTEA I have understood the Constitution and By-Laws of the association and I understand the
purposes and objectives of PBESTEA.

In this connection with such membership, I hereby agree to the following terms and / or conditions.

1.) To comply with the provision of the Articles, by law and policies set by the Officers, the General Membership
Assembly as well as the acts of duly constituted authorities of the Association and of failure on my part to do so,
the PBESTEA at its option, may fine, suspend me from membership where upon my rights and benefits shall be
waived.

2.) To attend all meetings, conferences and seminars and assemblies as required by the duly constituted authorities of
the Association.

3.) To pay the required registration, membership, and monthly dues.

4.) To comply with the directives of duly constituted authorities.

MEMBERSHIP DISCLOSURE

1.) I confirm that all information disclose in this member’s information sheet is correct and complete. Any changes in
foregoing information shall be communicated to the Association. I hereby authorize the Association to verify and
investigate any and all information given by me which the Association may deem appropriate.

2.) I hereby acknowledge and authorize the Association to use my given information by still enforcing data protection
and privacy laws.

The provision of this agreement, Articles of Association and By-Laws have been explained to me which I understood and agreed
upon. In all the above undertakings, I am aware that the duly constituted authorities of the Association and the PBESTEA may
impose sanctions against me or perform any act necessary to make that sanction/s effective without going to court.

In witness hereof, I have here unto affixed my signature / right thumb mark this day ________ of 20 ___.

IN CASE OF TRANSFER OF DISTRICT (station):

1.) Membership Fees and Registration Fee are Non-Refundable.

2.) The Member shall pay all his/her dues upon clearance.
3.) The Member’s benefits such as [Death Aid and Medical Aid] shall be waived and be declared null and void
effective upon transfer.

_________________________________________
Signature over Printed Name

Date Signed: ___________________________

ID Presented: __________________________
Expiration Date: ________________________

Padre Burgos Elementary & Secondary Teachers and Employees Association

PBCS •CES • DES • HES • KES • LES • PES • PIS • SES • VES • WES • YES
DNHS • HNHS • LGLNHS • SINHS