BATANGAS PUBLIC SCHOOL TEACHERS, EMPLOYEES AND

RETIREES ASSOCIATION INC. (BPSTERA)

Provincial Sports Complex Bolbok, Batangas City
Tel. No. 702-4174

APPLICATION FOR MEMBERSHIP

1. Name of Applicant: SANGALANG SHIRLEY DINGLASAN

_____________________________________________________________________
(Surname) (First Name) (Middle Name)
2. Age: _____53_______ 3. Sex: __ Female
____ 4. Civil Status: ___M __
5. Name of Spouse: ______HILARIO D.
SANGALANG________________________________________
6. Permanent Address: __Coral na Munti _____________Agoncillo______________ Batangas
______
(Street/Barangay) (Municipality) (City/Province)
7. DepEd Employee at present:___Pamiga Elementary
School_______________________________
a. Position: _____Head eacher
III_______________________________________________________
b. Entity:
_________Agoncillo_________________________________________________________
__
(District) (Secondary) (Division Office)
8. Name of School Division: __Division of Batangas
Province_______________________________
(Bats. Prov.) (Bats. City) (Lipa City) (Tanauan City)

9. Are you on sick leave of absence? ______No___ If so, why?

_________________________________
10. Beneficiaries: (If married, the spouse and the children are automatically the beneficiaries unless
otherwise signed in writing under oath)

NAME RELATION SHARES

Jherwin D. Sangalang Son

Note: if this space is not enough please use the reverse side to list the other beneficiaries:

Herewith attached are the following:

1. P/ 20.00- Membership- BPSTERA
2. P/ 20.00- Annual Due
3. P/ 20.00- Membership Fee- ASATA
4. P/ 45.00- Advance Abuloy good for 9 deaths
 BATANGAS PUBLIC SCHOOL TEACHERS, EMPLOYEES AND
RETIREES ASSOCIATION INC. (BPSTERA)
Provincial Sports Complex Bolbok, Batangas City
Tel. No. 702-4174

I hereby certify that the above information’s are true and correct. I further certify that
I have read the RULES and REGULATIONS governing the ASATA and shall abide fully by
the terms and conditions.

Date: ___October 07, 2021_____ _SHIRLEY D.

SANGALANG___
Signature of Applicant

APPROVED:
CONIE C. HERNANDEZ
BPSTERA-ASATA PRESIDENT/ MANAGER