JCIP Form 100A

Junior Chamber International Philippines

Developing Leaders for a Changing World VDF Control No. _______
(JCI Philippines Bldg.)
14 Don A. Roces Avenue, Quezon City
Tel. / Fax (02) 8374-4138
Website: www.jciphilippines.com Email:NOM@philjaycees.com

VOTING DELEGATES FORM

***************************************
LIST OF VOTING DELEGATES

NAME OF LOCAL ORGANIZATION (LO): ______________________________________ JCI REGION : __________________

ADDRESS : ___________________________________________________________________________________________

REGULAR VOTING DELEGATES

NAME SPECIMEN SIGNATURES DATE OF BIRTH

LO President
_______________________ ____________________________ _________________________

1. _______________________ ______________________________ ___________________________

2. _______________________ ______________________________ ___________________________

3. _______________________ ______________________________ ___________________________

4. _______________________ ______________________________ ___________________________

5. _______________________ ______________________________ ___________________________

6. . _______________________ ______________________________ ___________________________

7. _______________________ ______________________________ ___________________________

 Use additional sheet(s) if necessary

Photos
LO President

NAME :_____________________ _____________________ _____________________ _____________________

LO Position: ____________________ _____________________ _____________________ _____________________

NAME :_____________________ _____________________ _____________________ _____________________

LO Position: ______________________ ________________________ _______________________ _______________________

ALTERNATE VOTING DELEGATES

NAME SPECIMEN SIGNATURES DATE OF BIRTH

1. _______________________ ______________________________ ___________________________

2. _______________________ ______________________________ ___________________________

3. _______________________ ______________________________ ___________________________

4. _______________________ ______________________________ ___________________________

5. _______________________ ______________________________ ___________________________

6. . _______________________ ______________________________ ___________________________

7. _______________________ ______________________________ ___________________________

*Use additional sheet(s) if necessary
 Photos

NAME :_____________________ _____________________ _____________________ _____________________

LO Position : _______________________ _______________________ _______________________ _______________________

NAME :_____________________ _____________________ _____________________ _____________________

We hereby certify that the members whose names, signatures and photos appear above and in the preceding page(s) are registered
members in good standing of JCI Philippines, Inc. and the Local Organization JCI _________________________, and that the information
contained herein are true and correct.

_____________________________ ____________________________
LO SECRETARY LO PRESIDENT

SUBSCRIBED AND SWORN to before me this ___ day of ___________, 20____ at _______________________, affiants exhibiting
to me competent proof identity, viz;

NAME GOV’T. ISSUED ID ISSUED AT ISSUED ON

__________________________ __________________ _______________ ________________
__________________________ __________________ _______________ ________________
__________________________ __________________ _______________ ________________
__________________________ __________________ _______________ ________________
__________________________ __________________ _______________ ________________

NOTARY PUBLIC
Doc. No.
Page no.
Book No.
Series of 20____

DEADLINE : MUST BE SUBMITTED TO THE JCI PHILIPPINES SECRETARIAT ON OR BEFORE MIDNIGHT OF MAY 31 , 2021.

NSTRUCTIONS:

1. Please accomplish JCIP Form 100 in four (4) original copies and submit all copies to the JCIP Secretariat, through the
National Secretary General.
2. Please supply all the information required.
3. Please label photos by writing the name of the member and the LO at the back of the photo before attaching same to the form.
4. All copies of the form should have the photos of the voting delegates and alternates. Otherwise, same shall be disapproved.
5. This form must be accompanied by a duly notarized Board Resolution containing the names of the LO’s voting delegates.

Note: Any alteration (except as to the spaces for the regular and alternate voting delegates, as allowed) to or erasure on this form shall
be a ground for disapproval hereof.

VDF submitted to the JCIP Secretariat on ________________________ through:

________ Personal Delivery
________ Commercial Courier
________ Registered Mail dated __________

Receipt of VDF noted by:

___________________________
National Secretary General

VDF Approved by the National Comelec

____________________________
Comelec Chairman