(FOR RECOMMENDATORY PURPOSES ONLY) CERTIFIED LIST OF PUBLIC SCHOOL TEACHERS WHO ARE WILLING, AVAILABLE AND QUALIFIED TO SERVE AS MEMBERS OF THE ELECTORAL BOARDS FOR THE (ELECTION TO BE CONDUCTED i.e., OCTOBER 23, 2017 BARANGAY AND SK ELECTIONS) SERVEDINTHE | SIGNATURE OF THE APPLICANT PREVIOUS WILLING, REGISTERED | ELECTIONS AS NAME POSITION/ SCHOOL OF | AVAILABLEAND | VOTERWITH | MEMBER OF DESIGNATION | ASSIGNMENT | QUALIFIED! TO ACTIVE ELECTORAL —_| (The signature is an attestation to the BECOME A STATUS BOARDS truthfulness of all the facts indicated * | MEMBER OF THE (YES/NO) Af applicable, indicate in this Certificate) | ELECTORAL, the position held and | BOARD election year/s) = | (YES/NO) (YES/NO) | Thereby certify that the foregoing public school teachers are qualified, willing and available to serve as Members of the Electoral Boards for the (election to be conducted i.e., October 23, 2017 Barangay and SK Elections). ‘i Date ofthe Request of the OE: Date of Submission to the OEO: and Sis DepEd Official in the District, City or Municipality * Must be of good mona! character and ireproncuble reputation: Has never Ben canoe of ny lection fens or ny fie cme punishable ay mare than sx (6) months finprisomet: Has no pending Information ogaast hi for any lection offense; Abie o Speak and Whit Engi, Flpinoor the lcal dialect and of wn integrity and competenceWU) Subscribed and Swom to me this_ day of 1 Affiant exhibiting to me his/her competent evidence of identity: NOTICE/DISCLAIMER: AU! authorized recipients of any personal data, personal information, privileged * documents attached thereto that are shared by the Commission.on Elections in compliance with existing laws an Rules and Regulations, as well as the pertinent Circulars ofthe National Privacy Commission, ae similarly ‘Name and Signature ofthe Election Officer as Administering Officer information and sensitive personal information contained in this document, including other pertinent id rules, and in conformity with the Data Prioacy Act of 2012 (R.A. No. 10173) and is Implementing Bourd to comply with said laws, rules and regulations, relating to data privacy, secunty, confidentiality, protection and accountability.