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Republic of the Philippines
Department of the Interior and Local Government
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
REGION : CITY/MUN :
PROVINCE : BARANGAY :
SK Chairman IPMR
SK Member other Appointive Barangay Official:
TERM IN THE PRESENT POSITION:
1st 2nd 3rd
PERSONAL INFORMATION
(Last Name) (Suffix e.g. Jr., I, II,III) (First Name) (Middle Name)
OCCUPATION: HONORARIUM:
BENEFICIARIES:
NAME DATE OF BIRTH RELATIONSHIP
1.
2.
3.
4.
5.
I hereby certify that the above information are true and correct to the best of my knowledge.
CD/CLGOO/MLGOO Date
(Signature Over Printed Name)