Republic of the Philippines

Province of Kalinga
OFFICE OF THE SENIOR CITIZENS AFFAIR

Name: Herman M. Gammoot Age: 61 y/o Birth Date: October 23,1957 .

Address: New Balbalan, Lacnog,Tabuk City, Kalinga Occupation : Farming .
Income: Less than Php 35,000.00 per annum Skills: Carpentry .
Experience in Government: Barangay Tanod (2013-2015) or Private firm (Not Applicable) .

Do hereby pledge the following to wit:

1. That I will faithfully abides the rules and regulations promulgated by the constitutions and by-
laws.
2. That I will pay my membership fee up to date (Annually);
3. That I will contribute the amount of ________________ per dead member thru the TREASURER
OF THE ASSOCIATION;
4. That I am willing to give for any special contribution to the ASSOCIATION as the need arises;
5. That my beneficiaries are not entitled to any benefit, privileges from the Association if my
membership is questionable.
6. that my beneficiaries are entitled to receive the benefit;
7. That my beneficiaries are as follows:

NAMES RELATIONSHIP AGE

Marison B. Gammoot Son 18 y/o

Jayson B. Gammoot Son 15 y/o
Valerie B. Gammoot Daughter 11 y/o

APPROVED BY:

_____________________ ___________________
BRGY. Chapter President Applicant’s Signature

Date: ______________