PAMBANSANG TINIG AT LAKAS SA PANTALAN

Chapter: ___________________
2” X 2” ID
PICTURE

MEMBERSHIP PROFILE/APPLICATION LATEST

PHOTO

NAME: ___ SEX:

(Surname) (First) (Middle)
CIVIL STATUS: _______ HEIGHT : (m) __ WEIGHT:(kg) __
DATE OF BIRTH: PLACE OF BIRTH:
NAME OF SPOUSE: NO. OF CHILDREN:
ADDRESS:
TIN : ___________ E-MAIL ADDRESS: _________________________
TEL.NO. (Residence) (Office) _______ (Cell phone)
PLANTILLA POSITION : _____ ___STATUS OF APPOINTMENT:
PPA EMPLOYEE ID NO.: __________ACTUAL DESIGNATION (if any)
OFFICIAL STATION (Per Plantilla Item):
ACTUAL PLACE OF ASSIGNMENT:
FIRST DAY OF SERVICE IN (a) GOV’T: (b) PPA:
YEAR JOINED PANTALAN:___________________________________________________

CERTIFIED CORRECT: (By the Applicant)

Signature over Printed Name Date

Confirmed by:

Chapter President Chairman-Nat’l Membership Committee

Date Signed Date Signed

Noted:

EMILIANO M. ESPARAGUERA,JR.
NATIONAL EXECUTIVE PRESIDENT
Date Signed:_____________

AUTHORITY TO DEDUCT
For: The HR / Administrative Manager
HO / PMO

This is to authorize deduction of the following :

1. Membership Fee (P100.00) (For new members)
2. Monthly Dues
3. Mortuary Assistance (in case of death of a member)
4. Agency fees and
5. Other Union fees.

Please remit the said amount to the local PANTALAN Chapter.

__________________ _______________________
Date Signature over Printed Name