Republic of the Philippines

COMMISSION ON ELECTIONS
Manila
NOMINEE NO. ___________________

CERTIFICATE OF ACCEPTANCE
I, ________________________________________, a bonafide member of
__________________________________________ hereby accept the nomination as its party
list representative in connection with the May 13, 2015. Automated Synchronized National and
Local Elections, and after having been sworn in accordance with the law, depose and so state the
following:
1. FULL NAME: ______________________________________________________________
(Surname/ First Name/ Maternal/ Maiden Name)

2. PARTY/SECTORAL ORGANIZATION/ COALITION: ___________________________

3. DATE OF BIRTH: __________ PLACE OF BIRTH: _______________

AGE: ______

4. CIVIL STAUS: _________

IF MARRIED, FUL NAME OF SPOUSE:
________________________________________
(Maternal / Maiden Name)
5. I AM A NATURAL BORN FILIPINO CITIZEN\
6. PROFESSION OR OCCUPATION: ______________________________________
7. RESIDENCE (Complete/Exact Address): ________________________________________
(House No./Street/Municipality/City/Province)

_____________________________________
Instructions:
Prepare this form in twelve (12) legible copies, attach them to the Certificate of Nomination and submit to the Clerk of
the Commission,
COMELEC, Intramuros, Manila, on the following dates:
a.) For new applicants for the registration, not later than the last working day of March 2012 pursuant to Secs. 4, 5 &
7, Rule 1 of Resulution No. 9366 dated Febryary 21, 2012; and
b.) For duly registered party-list groups or organizations, on May 31, 2012 pursuant to Secs. 2& 3, Rule 3 of
Resolution No. 9366 dated February 21, 2012 in relations to Resolution No. 9359 dated February 8, 2012.

8. CONTACT NO. FOR ELECTION PURPOSES: ________________________________

9. NO. OF YEARS RESIDENCE IN THE PHILIPPINES IMMEDIATELY PRECEDING
THE MAY 13, 2015 AUTOMATED SYNCHRONIZED NATIONAL AND LOCAL
ELECTIONS: ______________________________
10. I AM A REGISTERED VOTER OF PRECINCT NO. ________, BARANGAY
_____________
CITY/MUNICIPALITY OF ____________________, PROVINCE OF
___________________.
11. I AM ELIGIBLE for the office for which I am nominated as I possess all the legal
qualification and none of the disqualifications. I will support and defend the Constitution of the
Philippines, and will maintain true faith and allegiance thereto; I will obey all the laws, legal
orders and decrees promulgated by the duly constituted authorities of the Republic of the
Philippines; and I impose this obligation upon myself voluntarily, without mental reservation or
purpose of evasion.
I hereby certify that the facts stated herein are true and correct of my own personal knowledge.
__________________________, 20
(Date)
_______________________________________
(Printed Name & Signature of Nominee)
(RIGHT THUMBMARK)
SUBSCRIBED AND SWORN to before me this ____ day of , at _______________,
affiants exhibited to me proof of his/her identity being ______________________ issued on
______________ at _________________ Philippines and valid until _______________.

_________________________________
(Officer Authorized to Administer Oath)
Doc. No. _________;
Page No. _________;
Book No. _________;
Series of

(Affix documentary stamp)