KALIPI NG LIPING PILIPINA

(KALIPI)
__________ Chapter

MEMBERSHIP APPLICATION
Name: _____________________________________________________________
(Surname) (Given Name) (M.I.)

Date of Birth : ___________ Age :____ Place of Birth : __________________

Purok / Barangay :__________________________ Occupation :_______________
Means of Livelihood :_______________________ Hobbies :_________________
Educational Attainment :______________________________________________
Seminar Trainings Attended : __________________________________________
__________________________________________________________________

Dependents:
NAME Relation Age Address

I hereby certify to the correctness of the above information and will abide to all
constitution and by-laws, rules and regulations of the association to the best of ability in
order to be entitled to all the privileges and benefits due as member. I am enclosing
herewith a membership fee of _____________( ₱ ______) and will pay such other dues
as required by the association.

__________________ Approved by:

Signature of Member

Checked by: ____________________

President
__________________
Secretary

_________________
Treasurer