‘Application No. Precinct No. 390130 instructions: (i) Accom ur NaMe moe aay aw 1 sees ise LL) asta RESIDENCE/ADDRESS Province |Metro Manila | sex City/Municipalty Barangay Male Female Manila { DATE OF ainri I House No, /stret Wont Bay Year Puace oF siRTH caren oy auth Inatuatned Rescued ers mn Fenn nt totter Cte Nate arrein) | Dateof Naturalization/ Month _Day__Year Cerificate No. /Order of Approval Reacqistion it STATUS PERIOD OF RESIDENCE single No.of Years oof Months woof Years warred inthe cyan nthe Pitppines Name of Spouse i Married PROFESSION / OCCUPATION 11% I OMT [ Jreaistearion [Treanseen "do solemnly swear that the above statements regarding my person are true and comec; that possess ll the qualfcatons and nene ofthe aquaificatons ofa voter and that 1 aml not registered in any precinct or L] registered In a precinct of another Ccty/Municpality/Disviet in the Philippines. Further, | give consent tothe processing of and other purposes as may be provided by law including BP. lg 881, RA. No, $189, RA "No, 10367 and R.A 10173 also know asthe Data Privacy Act of 2012. Lert Thumb | Right Thumb ate Wont Bay Year 1 Sanatre of Aptian hove Pied 2 Marijune P. Uriarte £0 /Adminstering Oise 3 one) EN an a) Month Day. Year Approved Win Precinct Aigner Ho I (cisapproved oare eas or eaorovl Adulfo S. Amit Marijune P. Uriarte Rosario D. Francisco Member Chairman of the Board Member (Satur shove Peed Na) Cnatre above Printed ame) (Senatar shove eM) Emu) Type of Application ‘ACKNOWLEDGEMENT RECEIPT Applicaton no. Srepuron Q trast th Reacvaon Bay. 390130 © Transier © change oftame/orrection of Entry Thee te was oP Ya O reactivation O reinstatement/inclusion Prec. no. ___ sparen. vow spscaton stat ‘Application for Registration Date 2 a mn ens mtg ee te ] Marijune P. UriarteREVISED CEF - 1 Republic ofthe Philippines COMMISSION ON ELECTIONS Instruction: FilLin completely and legibly the appropriate spaces and check appropriate choice’s in ovals. © APPLICATION FOR REGISTRATION (Accomplish Personal information atthe back) ‘Note (Far Applicants with oxstng Rogtraton Records) I . Filipino, born on a duly registered voter in Precinct No. of Barangay , City/Municipality of z Province of . do HEREBY APPLY FOR: (Check appropriate boxes) © APPLICATION FOR TRANSFER OF REGISTRATION RECORD within the same City/Municipality/District from another City/Municipality/District (Accomplish Personal Information at the back). My New Residence is: House No. & Street. Barangay. Cilyinaunicipaliy, Province. have resided in my new residence for years and for ‘months. © APPLICATION FOR REACTIVATION OF REGISTRATION RECORD Reason for Deactivation: © 1 Sentenced by final judgment to suffer imprisonment for not less than one (1) year: © 2 Convicted by final judgment of a crime involving disloyalty to the duly constituted government, et: ‘© 3. Declared by competent authority to be insane or incompetent © 4 Failed to vote in two (2) successive preceding regular elections; QS. Loss of Filipino citizenship; or © 6. Exclusion by a court order. © 7 Failure to Vaidato That said ground no longer exists, as evidenced by the attached certfcation/order of the court (in cases of 1,2,3,5, and 6). © APPLICATION FOR CHANGE OF NAME DUE TO MARRIAGE OR COURT ORDER/CORRECTION OF ENTRIES IN THE VOTERS’ REGISTRATION RECORD (tach required supporting documents such as Certified Copy or Cerificate of Court Order or Certficate of Live Birth, and others) Present Data/Information: NewiCorrected Data/Information: © APPLICATION FOR INCLUSION OF RECORDS IN THE BOOK OF VOTERS / REINSTATEMENT OF NAME IN THE LIST OF VOTERS © Inclusion of VRR in © Reinstatement of the name of the registered voter which the precinct book of voters has been omitted in the list of voters | do hereby request that my name which has been omitted in the list of voters/my registration record which has not been included in the precinct book of voters of Precinct No. be reinstated/included therein. The said reinstatement of ame/inclusion of registration record is necessary and valid. IN WITNESS WHEREOF, | hereunto affix my signature this day of (2021 at Manila Province of __ Metro Manila Philippines. ‘Signature above printed name SUBSCRIBED AND SWORN to before me on the above date. Marijune P. Uriarte EO/Administering Officer