Republic ofthe Philippines

COMMISSION ON ELECTIONS
Manila

1 INSTRUCTIONS: (Readwell before filling up this forrn.)

1. File this in AVE (5) LEGIBLEcopies.
2. File this certificate of candidacy with the Law Department, COMELEC Main Office, Intramuros, Manila, starting November 20, 2009 up to
midnight of Novem~ 30, 2009.
3. Attach to this certificate the Certificate of Party Nomination unless you are an Independent candidate. After midnight of November 30, 2009, no
certificate of nominationshall be accepted.
4. TRIes such as 'Dr., Atty., Don, Ginoo, Senor Datu, Hadjl, Sultan, Bait Senora, Kapitan or similar titles are expressly prohibited.
l

5. This certificate shall be sworn before a notary public or any oJficial authorized to administer oath. COMELEC officials are not authorized to
administeroath.

1.1 Last Name

o Male 45
5. MY DATE OF BIRTH IS :
1.2 First Name

1.3 l'liddle Name

i :D[q:;-:'-'-,:",,',:-~ :I:::~
Nonth Day Year
I~:~:
6. MY PLACE OF BIRTH IS :
2. I AM GENERALLY OR POPULARLY KNOWN ay THE NICKNAME OR STAGENAME
City/Mun :tJftJ~!...,,,...,,.," ,'..' ..
l~T.',T',::,', :~.'',,l'.',1:'T, '.::: J:: 1:::::::~::::: .: ' ' [::[ :::',: J', 'T',I:::
'Indicate only one nicknameor stagename)
9f 6.tJ,llttl, .vtt"/it'l
[~]E.::~'J\
1--------~~--~~~~~--~~~--~~~~~~--~~--~~~------~--~+8.MYCIVILSTATUSIs:
Province " _

~Illi!li;;' .....----,.,',,,----...' ,,,.'.,.,.,..,.',,''.'., D 0

7. I AM OFFICIALLY NOMINATED ay: (Attach Certificateof Nomination)
Single Widow/er
, -- , , ' , . , .. -- , .Pr.N.L,. , ,~f'r,e ~.TtRt\-N,, , ,P
[ZJ D
9. MY RESIDENCE!
ADDRESS IS:
9.2 City!Nunidpalily
9.1 Province

9.3 Barangay
o Married

Annulled/ Divorced

Full Name of Spouse, if married

legally Separated

vft\lfl'lr~l-lf'.. _q-~... -rfl:m'R'I.P .... __.

• - • , ••

: .LI ,,:
. '1.,
",- •• r • - ,. - ',' - ','

p:n : f(: 0 :.t : . . . . : . . : :.

... ,'T!.! ... /':-.,. .v , ,!,,!,,:,'
- - '" - ••. - - • - - •• - - ",-

-",
- ',' - • ,- - • (' - - :

.v , , ..... , ... !.,.

>..,>: 1'/
.'

~~
- •• - • -,-

:~~""
• -

: .a..: '<7
.', ... : ~~ -"lV,. __ ,."
:0 >': I :0: ':
r • - , • - -,- - "," - • r - - •.• - • - • -," - -,' - - r - -.- • -,

.--,-Y,:,,: __.'. .', __'",

~~~
10.
__
..•...•.•.•...•..•.
MY PROFESSION OR
~~ .•.•.....•.•..•....•..•...•...•
i2:'0':" ': ~:A':'i-T~';?~]i:-~'i~':';'r~'[":~:;:)":'--;"':":" ~'.T' .: .~'':. ';-- ':"~'" .~~v.~~
9.4 House NO./ Street /Subdivision OCCUPATION IS :
.f!<jJf:,~., (P.1fJj~~".

11. MY POST OFFICE ADDRESS FOR ELECTION PURPOSES IS : (Couldbe the sameas No.9) 12. I AM A REGISTERED VOTER OF

Precinct •. _ .OOtbA .... ,', __.... _

13. MY PERIOD OF RESIDENCE IN THE PHIUPPINES BEFORE MAY 10, 2010 IS :
~y __ ~NTR().I2..( fQfjv. __ .
: I:I : No. ot eiontns
~';I.':';: No. of Years
Oty/Mun ., ' , ,&PI>!~R l,,,.',',.,' ,,,.
. .".. '---,vI .
.... Province '" ,CAG-MRN .. , ' .. ,., ,.,.',"
~----------------------------------------------------------;
14. I AM A NATURAL BORN FILIPINO CrnZEN.
15. I AM NOT A PERMANENT RESIDENT OF, OR IMMIGRANT TO, A FOREIGN
COUNTRY.
16. I AM ELlGIBLE FOR 'THE OFFICE I SEEK TO BE ELECfED TO.
17. I WILL SUPPORT AND DEFEND THE CONSTITUTION OF THE REPUBLIC OF THE
PHILIPPINES AND WILL MAINTAIN TRUE FAITH AND ALLEGIANCE THERETO. I
WILL OBEY THE LAWS, LEGAL ORDERS AND DECREES PROMULGATED BY THE
DULY CONSTITUTED AUTHORITIES. I IMPOSE THIS OBLIGATION UPON MYSELF
VOLUNTARILY, WITHOUT MENTAL RESERVATION OR PURPOSE QF EVASION .
.r"

I hereby certify that the facts st~ted herein are true and CQrrect~~a~e.

B~[ Signature of candidate

~Ay~
OVer Printed Name

GSIS SUBSCRIBED AND~WORN

. N OV 2 0 ?009
to before me this __ day of November, 2009,"dE
~~~~,OF SAN JUAN
,
.
affiant exhibiting to me
"B"C/ldentiflcation Card No. & 4- lfo I!o;;J,?J.- [ Issued by : On : _

Doc. No. 3{p1

Page No.
Book No. __
*'-
?
"'~=-
__
_______
(Officer Authorized to Administer Oath)
--','-"""'ATTV. BENZ
NOrMY PUBLIC
UDD C.
Series of 200.:1 (Affix documentary stamp) C'OMM!S~fL)NEu UNTIL:: 1 • t ..2009
IBP LRN No. 07232 <ii;: !\l. <l~N~:'.I.~N
pm No. O;)7G18G--O.j:J6i,]~j- S~J.I,JliAN
Pl~LLNo. S!.}t~47