LAV Forni No. 01 O Republic of the Philippines COMMISSION ON ELECTIONS is Committee on Local Absentee Voting MAY 9, 2016 NATIONAL AND LOCAL ELECTIONS APP! ATION TO AVAL -AL ABSENTEE V' 1.PERSONAL DATA: (Please use the same name as appearing in your registration record.) (a) Name: - - - Garmame) Girst name) (Middle name) (b) Sex: Male (remale (c) Civil Status: [J single LD Married Widow/er (4) Date of Birth: - (@ Contact Numbers: Mobile: Email address: Place of Birth: __HQ/Office Tel. No = 2. 1AM A REGISTERED VOTER OF;(Note: Please go to comelec,gov.ph/2r=VoterRegistratinn /Registration: enifigation/presauct finder for information on the following data.) (0, (Precinct No,/Barangay) (City/ Municipality) (Province) (g) Voter's Registration Record Number (VRRN) (h) Voter's Identification Number (VIN) 3. 1 WANT TO AVAIL OF LOCAL ABSENTEE VOTING BECAUSE I WILLBE ASSIGNED ON ELECTION DAY TO PERFORM ELECTION DUTIES/COVER AND REPORT ON THE \ CONDUCT OF ELECTIONS OUTSIDE THE PLACE WHERE I AM A REGISTERED VOTER Please check the appropriate box: { L_] tama government official /employee | Government Office _ | Position _ Place of Assignment Name of Head of Office/Supervisor (i) [Jama member of the PNP Position /Rank. Place of Assignment Name of Station Head - | 0 (Jt ama member of the AFP Rank, | Unit. Serial Number = Place of Assignment z as Name of Commanding Officer wo [Cama member of the media — | Position, Place of Assignment __ | Name of Head of Company. « \s Thereby certify that the above declarations are true and correct. SUBSCRIBED AND SWORN 2016 at to before (Signature of applicant above printed name) me this _ day of Philippines. (Signature above printed name) Officer Authorized to Administer Oath