ID picture must be taken

LOCAL OFFICIALS’ INFORMATION SHEET within the last 6 months

(2x2 size) and with full and
handwritten name tag and
signature over printed
name.

INSTRUCTION: PLEASE FILL UP THE FORM LEGIBLY AND ALL CAPITAL LETTERS/ CAPSLOCK FORM. Computer generated
or photocopied picture
is not acceptable.
LGU:

First Name:
Middle Name:
Last Name:
Suffix:
Position:

Address:
Mobile Number:
Date of Birth: Blood type:
Birth Place:
TIN #:
GSIS/ SSS ID: Policy #:
PhilHealth #:
Height: Weight:

In case of emergency, please notify this person:

Name: Relation:
Address:
Contact Number:

SIGNATURE OF THE OFFICIAL:

PLEASE SIGN INSIDE THE BOX AND USE BLACK SIGN PEN/ DARK BALL PEN