evSeD vERSION:03-2021 CNew 1] Updating ge “~ ANI AT KITA =i * RSBSA ENROLLMENT FORM Reference Number- as 2x2 PICTURE PHOTO TAKEN \WITHIN 6 MONTHS ‘MIDDLE NAME EXTENSION NAME sex: O Male CO Female eS —— ——— —o tJtittT tt) DPre-schoot Ci Junior High school (K-12) [] Vocational = Ditigh school nonk-12) C) college Done Tenson wit DEARLITY(uDy, C]Yer EIN oe ee atl 7 iene 4P’s Beneficiary? Oyves ONo CPmESTATU: C Sogle C1 Marie! [1 Wiowed C1 Sepwae | tecetatcreigeemeegs Ene Line IF MARRIED: yes. specify ‘With Government? [] Yes [No cra MAIDEN NAME: If yes speciy 10 Type: uae HouseHoLD HEAD? = Yes CI No ‘Member of ony Formers Assodation/Cooperative? Cl Yes LINO No. of living household members: ‘CASE OF EMERGENCY: No. of mate: No, of female: | WAN UVEUNOGD —CIrARMER CL FARMMORKENLASORER——_L] BSMERFOLK Dieieon ‘For farmers: For farmworkers: ‘For fisherfolk: For agri youth: Type of Farming Activity Waa Were Soeiectiitetesed Aquat Reece: BA | cokers nclcaerpepetaciard Chee Di tand reparation Aare ie ods || Ocom Di Planting/transplanting rege “under the Muniioal Regraton ‘Type of involvement other crops, Cl cultivation ‘Typset Fishing Acty Tlattensinglattended formal please specify: CO Hanes Fish Capture 1 Fish Processing a Ci tivestock, a Ci Aquacuiture Fish Vending a foc ee Grose Annual Income Last Year: Farming Nan farming oa Reference Number: q Registry System for Basic Sectors in Agriculture (RSBSA) ENROLLMENT CLIENT'S COPY THIS FORM IS NOT FOR SALENo. of Farm Parcels: [Name of Farmer/sin Rotation: P). 2) 63) ——— aa weet FARM Livestock/Poultry/ WeAD | armTvee | cei parce FARM LAND DESCRIPTION. Thrcahen) | SEA) | rss seacrmonen | REMARKS seta |” | Si eee ee + fomnneteanennes Sn omni janes oe 7 | Perera TO cae a ee oa onan oe ce ee! Bi asa aor) ee weiner oe aaa ee re = 2. Emancipation Patent, rebate sop ni 2 dena tt Soccer 2: be Oumership Award (CLOA) AL Getfcate of Ancestral Land Tie er ea "Thereby declare that allnformation indicated above ae tue and correct, and that they may be used by Department of Agriculture fo the purposes of regjstration tothe Registy System for asic Sectors in Agriculture RSBSA) and other legitimate interests ofthe Deparment pursuant ois mandates, ‘VERIFIED TRUE AND CORRECT BY: RAUBER OVRCER STohntaNet MS VEROER MOEN the) __CITY/MUNICIPAL AGRICULTURE OFFICE ‘CAFC/MAFC CHAIRMAN Primer ‘The collection of personal information i for documentation, planning, reporting and processing purposes in availing agricultural related interventions. Processed data shall only be shared to partner agencies for planning, reporting and other use in accordance to the mandate of the agency. Tis i in compliance with the Data Sharing Policy of the department "You have the right to ask for a copy of your personal data that we hold about you as wel as to ask for it to be corrected if you think tis wrong. To 4050, please contact THIS FORM IS NOT FOR SALE \VERIFIED TRUE AND CORRECT BY: EMESIS Stet etnscr OFFIC BASEN, ‘CITY/MUNICIPAL AGRICULTURE OFFICE CAFC/MAFC CHAIRMAN VtRASER AR a