Republic of the Philippines APPLICATION FOR REACTIVATION OF

COMMISSION ON ELECTIONS REGISTRATION RECORD

Mark Rowell/ Gohing/ Prado Mar /26 /1990

I, , Filipino, born on
First Name/Middle Name/Last Name month/day/year
217D Guinha laran
a duly registered voter in Precinct No. of Barangay ,
Silay City Negros Occidental
City/Municipality of , Province of . ,
single/widow/er/legally separated/married to . _____ , do hereby apply for
the reactivation of my registration record which was deactivated due to (please check appropriate box):

__ 1. Sentence by final judgment to suffer imprisonment for not less than one (1) year;

2. Conviction, by final judgment, or crime involving disloyalty to the duly constituted government, etc;

I | 3. Declaration of insanity or incompetence by a competent authority;

__ 4. Failure to vote in two (2) successive preceding regular elections;

I I 5. Loss of Filipino Citizenship; or

!_
E __ 6. Exclusion by a court order.
_i

That said ground no longer exists, as evidenced by the attached certification/order of the court (in case
i
UJ
of 1,2,3,5 and 6).
u
UJ
26th April
IN WITNESS WHEREOF, I have hereunto affix my signature this day of 20 22 at
O
u- Iloilo
Iloilo City , Province of Philippines.
t
s
Mark Rowell G. Prado
(Signature above Printed Name)

SUBSCRIBED AND SWORN to before me on the above date.

EO/Chairman of the Election Registration Board

(Signature above Printed Name)

N o t i c e t o t h e a p p l i c a n t : If your biometrics, i.e. photograph, signature a n d fingerprints had not been captured digitally, please accomplish the form
at the back.
AppI cation No. Precinc* No.

Instructions : (1) Accomplish separately in three (3) copies; (2-) print legibly; (3) check the appropriate box.

PART 1 PERSONAL INFORMATION (To be filled out by Applicants)

•
NAME
r Disabled / Person
^] Illiterate
Last ! with Disability
J....1.
First T~"T Assisted b y : .
>M| (Please fill-up Assistor's O a t h )

Middle)
: i "] T"
T T T GENDER
J Female
J Male
RESIDENCE/ADDRESS Province
Height Weight

City/Municlpallty Barangay
DATE OF BIRTH
Ml! rTTTTTTT"
House No. / Street I I I . I l l II. Month Day Year

I I j 1 i I j 1 PLACE OF BIRTH
1CITIZENSHIP
J L i J J. i | | By birth • Naturalized | | Reacquired Clty/Mun

(If naturallzed/reacqulred, state date of naturallzatlon/reacqulsltlon and Certificate Number of naturallzatlon/order of approval of reacquisition) Province

Month Day
Date of Naturalization/ Year Certificate No./Order of Approval CIVIL STATUS
Reacquisition
m-m-LLTij [ | Single ^jwidow/er

PERIOD OF RESIDENCE Married ^Legally

No. of Years No. of Months No. of Years
r—* 1 Separated
In the City / Mun
J M l In the Philippines j j j Name of Spouse, If married

PROFESSION / OCCUPATION TIN

NAME OF FATHER NAME OF MOTHER
Last
1 ' j j j I i i
1
i
T
j ! ! | Last j
1 i ! i
j i j 1 i j j j j ]
i • >

First ! ! ! ! ! J ! !1 I1 T | j First ! j !'""![""

• < •
! : : : i
. T 1 1 i i T i T i i i i i i i l i
Middle: ! 1 i 1 i i : i i I j j Middle! j j
j J. i....I_„.i 1 I....L J....1 t....i...i j
PART 2 OATH ROLLED THUMBPRINTS / SPECIMEN SIGNATURES

I d o solemnly swear that the a b o v e statements regarding my person are

t r u e a n d c o r r e c t ; t h a t I p o s s e s s all t h e q u a l i f i c a t i o n s a n d n o n e of t h e
disqualifications of a voter; that I have no pending application for registration
In any city/municipality.

f f
Month Day
J - L. JLLJ S i g n a t u r e of A p p l i c a n t
Year
A b o v e Printer/ N a m e
Left T h u m b Right T h u m b

E O / A d m i n i s t e r i n g Officer
2. 3.
(Signature a b o v e Printed N a m e )

PART 3 ACTION BY THE ELECTION REGISTRATION BOARD

Day Year

QTIJ
_ r
_ Approved With Precinct Assignment No.
i. i. J L
Disapproved Date
Reason for Disapproval

Member Chairman of the Board Member

Signature above Printed N a m e Signature above Printed Name Signature above Printed Name

PART 4 VOTER IDENTIFICATION NUMBER (To be filled out by Election Officer)

OTY/MUN/

DISTRICT C O D E NAME C O D E

PRECINCT NO DAY

DATE OF BIRTH
 CEF-1C

Republic of the Philippines APPLICATION FOR REACTIVATION OF

COMMISSION ON ELECTIONS . REGISTRATION RECORD

i, , Filipino, born on
First Name/Middle Name/Last Name month/day/year
a duly registered voter in Precinct No. of Barangay
City/Municipality of , Province of
single/widow/er/legally separated/married to , do hereby apply for

the reactivation of my registration record which was deactivated due to (please check appropriate box):

I I 1. Sentence by final judgment to suffer imprisonment for not less than one (1) year;

I I 2. Conviction, by final judgment, or crime involving disloyalty to the duly constituted government, etc;

__ 3. Declaration of insanity or incompetence by a competent authority;

__ 4. Failure to vote in t w o (2) successive preceding regular elections;

_
u • 5. Loss of Filipino Citizenship; or

6. Exclusion by a court order.

Ja That said ground no longer exists, as evidenced by the attached certification/order of the court (in case

of 1,2,3,5 and 6 ) .

UJ
UJ
IN WITNESS WHEREOF, I have hereunto affix my signature this day of _ 20 at

, Province of , Philippines.

8 (Signature above Printed Name)

SUBSCRIBED AND SWORN to before me on the above date.

EO/Chairman of the Election Registration Board

(Signature above Printed Name)

Notice to the applicant: If your biometrics, i.e. photograph, signature and fingerprints had not been captured digitally, please accomplish the form
at the back.
 Application No. P r e c i n c t No.

Instructions : (1) Accomplish separately in three (3) copies; (2) print legibly; (3) check the appropriate box.

PART 1 PERSONAL INFORMATION (To be filled out by Applicant)

NAME
I 1 I 1 uisaDiea/ Vkcto*
Last t i l l !

First i
J Illiterate J^^tCVwt*M^

Assisted by (Please fill-up Assistor's Oath)

• •
Middle ! GENDER
Male Female
i i i i
RESIDENCE/ADDRESS Province | i
Height Weight
City/Municipality Barangay DATE OF BIRTH
f j ] [ I I [ i
I I ! i ! !

House No. / Street Month Day Year

i i I i i I PLACE OF BIRTH

CITIZENSHIP • BY Birth ^Naturalized J Reacquired City/Mun

(If naturalized/reacquired, state date of naturalization/reacquisition and Certificate Number of naturalization/order of approval of reacquisition) Province

Date of Naturalization/ Month Day Year Certificate No./Order of Approval CIVIL STATUS
. . ; r 1 ; r ' ; . J
Reacquisition | i i - I ; i - j j ; ; i
^jwidow/er

•
Q]single
PERIOD OF RESIDENCE ~] Legally
No. of Months No. of Years Married
No. of Years
Separated
In the City/Mun j I j In the Philippines i i |
Name of Spouse, if married

. PROFESSION/OCCUPATION TIN
..i i J L.

NAME OF FATHER NAME OF MOTHER

~l Last Last [ I I I !

First i I I First i i
r r r
Middle; i i i i i i
j | j
.L..J i i i i L.J i I J
I i !
Middle; I j
i
i
i
l I 1f T i l
! • ! ! ! ! ! !
PART 2 OATH ROLLED THUMBPRINTS / SPECIMEN SIGNATURES

I do solemnly swear that the above statements regarding my person are

true and correct; that I possess all the qualifications and none of the
disqualifications of a voter; that I have no pending application for registration in
any city/municipality; and that I am not registered in any precinct in the
Philippines

DATE i ;-!
Month Day Year Signature of Applicant
Above Printed Name Left Thumb Right Thumb

EO / Administering Officer 2. 3.
(Signature above Printed Name)

PART 3 ACTION BY THE ELECTION REGISTRATION BOARD

Approved With precinct assignment No.

Disapproved Date
Reason for Disapproval

Member Chairman of the Board Member

(Signature above Printed Name) (Signature above Printed Name) (Signature above Printed Name)

PART 4 VOTER IDENTIFICATION NUMBER (To be filled out by Election Officer)

CITY/MUN
DISTRICT CODE NAME CODE

YIAR
• DATE OF BIRTH •

ACKNOWLEDGEMENT R E C E I P T

Application No. j
Application for Registration
This is to acknowledge receipt of your Application for
registration. You are not yet registered unless approved by
" 1 T i t h
Election Registration Board/(ERB). You need not appear
e

Last ,J j. I In the ERB hearing unless required through a written notice.

First

Middle [ j
i. l J i J _ I i. _. I JL..
EQ/Interviewer Signature Above Printed Name
 Republic of the Philippines APPLICATION FOR REACTIVATION OF
COMMISSION ON ELECTIONS REGISTRATION RECORD

I, , Filipino, born on
First Name/Middle Name/Last Name month/day/year
a duly registered voter in Precinct No. of Barangay
City/Municipality of , Province of ,
single/widow/er/legally separated/married to _ , do hereby apply for
the reactivation of my registration record which was deactivated due to (please check appropriate box):

I J 1. Sentence by final judgment to suffer imprisonment for not less than one (1) year;

[_ 2. Conviction, by final judgment, or crime involving disloyalty to the duly constituted government, etc;

I I 3. Declaration of insanity or incompetence by a competent authority;

__ 4. Failure to vote in two (2) successive preceding regular elections;

_
5. Loss of Filipino Citizenship; or

_ 6. Exclusion by a court order.

That said ground no longer exists, as evidenced by the attached certification/order of the court (in case

of 1,2,3,5 and 6).

UJ

P IN WITNESS WHEREOF, I have hereunto affix my signature this day of ,20 at

2 , Province of , Philippines.

(Signature above Printed Name)

SUBSCRIBED AND SWORN to before me on the above date.

EO/Chairman of the Election Registration Board

(Signature above Printed Name)

Notice to the applicant: If your biometrics, I.e. photograph, signature and fingerprints had not been captured digitally, please accomplish the lomi
at the back.
 Application No. Precinct No.
i—r
• !

[, Instructions ; (1) Accornplish separately In three (3) copies; (2} print legibly; (3) check the appropriate box,

PART 1 PERSONAL INFORMATION (To be filled out by Applicants)

NAME
Last ! r~ T I T ' TTl
J Illiterate
• Disabled / Person
with Disability

Fin* [ 1 j f | T 1
i
! i 1 I1 1 i !
Assisted by:.
(Please fill-up Assistor's Oath)
Middle! 1 i 1 1 i ! ! 1
GENDER

J Male 1 Female
RESIDENCE/ADDRESS Province i j i ! i |
-J 1.1 ..1..1...L1...L.L Height Weight
City/Municipality Barangay DATE OF BIRTH

L—L...J L—I—L. ..L....L. 4„—l_—1 1—i—J—L J—L—t j..—l.—j

House No. / Street Month Day Year
I ! I T"""T
: i :
PLACE OF BIRTH
Li. ,t.
i

CITIZENSHIP • «y birth _] Naturalized J Reacquired City/Mun _ _ _ _ _

(If naturalLzed/reacqulred, state date of naturallzatlon/reacqulsltlon and Certificate Number of naturalization/order of approval of reacquisition) Province

Date of Naturalization/ Month Day Year Certificate No./Order of Approval CIVIL STATUS
...... f .....
Reacquisition J Single []widow/er
...J ! • L...L...i
PERIOD OF RESIDENCE

In the City / Mun

No. of Years
j i i
No. of
. . Months
.
In the Philippines
No. of Years
I—I
• Married Legally
Separated
Name of Spouse, if married

PROFESSION / OCCUPATION TIN ! I - I

I
J L
NAME OF FATHER NAME OF MOTHER
U s t
i ! 1 I I 1 1 i | i | Last j
T

Rnt
j i !
First | i ! ! !

.......—.„.._.......... —
Middle!
.1 t J...J Middle I r

i i i : i :

PART 2 OATH ROLLED THUMBPRINTS / SPECIMEN SIGNATURES

I do solemnly swear that the above statements regarding my person are

true and correct; that I possess all the qualifications and none of the
disqualifications of a voter; that I have no pending application for registration
in any city/municipality.

"| f"
I J J J 1.
Day Year Signature of Applicant
Month
Above Printed Name Left Thumb Right Thumb

2. 3.
EO / Administering Officer
(Signature above Printed Name)

PART 3 ACTION BY THE ELECTION REGISTRATION BOARD

Month Day

_ Approved With Precinct Assignment No.

...J J I i..' ] - r
E D
..J L
"1 Disapproved
Date Reason for Disapproval

Member Chairman of the Board Member

Signature above Printed Name Signature above Printed Name Signature above Printed Name

PART 4 VOTER IDENTIFICATION NUMBER (To be filled out by Election Officer)

CITY/MUN/
DISTRICT CODE NAME CODE

PRECINCT NO. DAY YEAR

DATE OF BIRTH