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BOIS FORM 2022 WORD
BOIS FORM 2022 WORD
(Last Name) (Suffix e.g. Jr. I, II, III) (First Name) (Middle Name)
Occupation: HONORARIUM:
BENEFECIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP
1. ________________________ ____________________________ _________________________
2. ________________________ ____________________________ _________________________
3. ________________________ ____________________________ _________________________
4. ________________________ ____________________________ _________________________
5. ________________________ ____________________________ _________________________
(Please use additional sheet if necessary)
I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.
_________________________ _________________________
(Signature over Printed Name) (Date Accomplished)
__________________________ _________________________
CD/CLGOO/MLGOO (Date)
(Signature over Printed Name)