ALLIANCE OF CONCERNED TEACHERS

NATIONAL CAPITAL REGION UNION

CSC ACCREDITATION NO. 864
Telefax 285-9948/Mobile No.09334886848;09479743918/actncrunion2017@gmail.com

APPLICATION FOR MEMBERSHIP

I hereby apply for membership with the Alliance of Concerned Teachers—National
Capital Region. I will abide by the Union’s Constitution and By-Laws and actively
exercise my duties and responsibilities as a member.

Name: ✓ TORRICER LEVIE ANN L.

Family Name First Name MI

Address: BLOCK 8 LOT 5 PHASE 1 LUPANG PANGAKO PAYATAS B, QUEZON CITY

School: ✓ LUPANG PANGAKO ELEMENTARY SCHOOL

Teaching Designation: T-I Sex: F Age: 25 Civil Status: SINGLE Blood type: A Years of Service: 2

Grade/Year/ Subject/s taught: III/ / MATH, MAPEH, FIL. Birthday: 08/22/94 Tin No.: 452-978-876-000

GSIS/ SSS No.: 2005320366 Contact No: ✓ 0935-0889-333 Email Address: heartyangel91@gmail.com

APPROVED BY:

MR. VLADIMER A. QUETUA

President

UNION DUES/MONTH

The monthly dues of members of the Alliance of Concerned Teachers-NCR as stated in Article of the Constitution and
By-Laws of the UNION approved in its Founding Assembly on November 11, 2011 amounts to twenty pesos (P20.00).

I am authorizing the check off of twenty pesos (P20.00) from my basic salary as my monthly union dues.

✓ _ LEVIE ANN L. TORRICER_ _ _ _ _ _ _ ✓ NOVEMBER 14, 2019

_ _
Name and Signature Date accomplished

Division: ✓ QUEZON CITY

Station No.: ✓
Employee No.: ✓ 5910372