Republic of the Philippines

Office of the President

NATIONAL TELECOMMUNICATIONS COMMISSION
National Capital Region
Quezon City SHEET
INFORMATION

INFORMATION SHEET
Any deliberate emission or distortion of material facts may give sufficient cause for denial of application.
1. Name _____________________________________________________________________ __________
(Surname) (First Name) (Middle Name) (Alias)
2. Change of name (if court action, give details) _______________________________________ __________
3. Birth date ________________ Birth Place _____________________________________________________
4. Citizenship _____________________, if naturalized, state previous citizenship, place date and Naturalization
Certificate No. _______________________________________________________________
5. Physical Description: Sex: ____________Height (cm) _____________Weight (kg) ___________________
6. Civil Status: ____________ Name of Spouse: ______________________________________________
7. Name of Mother: ______________________ Occupation: _______________________________
8. Name of Father: _________________________ Occupation: ________________________
9. Name of Brothers and Sisters:_____________________________ ______________________________
10. Home Address: _______________________________________________________________ __________
Tel. No. _____________________ _____ Cell Phone No.
11. Place of Residence since birth: ________________________________________________________________
12. Employment:
Name of Employment/Company/Office: _____________________________________________ __________
Name of Business: _____________________________________________________________ __________
Designation/Position: ___________________________________________________________ __________
Business Address: _____________________________________________________________ __________
Telephone No. ___________________________ Fax No._____________________________ __________
13. Schools Attended:
Name of School Location Course/Degree Date
Secondary:____________________________________________________________________________
College: ______________________________________________________________________________
Others: _______________________________________________________________________________
14. List of Organization of which you are/have been a member (Schools, Civic or Religious Organization):
Organization Address Position Inclusive Dates
____________________________________________________________________________ __________
Have you been arrested, convicted for any violation of laws or charged in any administrative case? ____,
if yes, state the name of court, nature of offense and disposition of the case
____________________________________________________________________________ __________
I CERTIFY that the foregoing are true and correct to the best of knowledge and belief and I AGREE that any
misstatement or omission as to the material fact(s) will constitute ground for immediate denial of my application.
Signed at ____________________________________________ Date ___________________ __________

_______________________________
(Name and Signature of Applicant)

Subscribe and sworn to before this ________th day of _________________________________ __________

affiant having his/her Residence Certificate No. _______________________________________, issued at
______________________________________ issued on _______________________________ __

Doc. No. ______________

Page No. ______________
Book No. ______________
Series No. ______________

NOTARY PUBLIC