BSB Form No. 1 s.

2023

1X1
ID PICTURE
Republic of the Philippines
Province of Leyte
MUNICIPALITY OF BURAUEN

BARANGAY OFFICIAL’S INFORMATION SHEET

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Secretary

Sangguniang Barangay Member Barangay Treasurer
SK Chairperson Barangay Tanod
Sanggunian Kabataan Member Barangay Nutrition Scholar
Day Care Worker
TERM IN THE PRESENT POSITION: Member of the Lupong Tagapamayapa
1st Barangay Health Worker
2nd Other appointive barangay service personnel:
3rd _______________________________________

PERSONAL INFORMATION

(Last Name) (Suf x) (First Name) (Middle Name)

(Birth Date: mm/dd/yy) (Birth Place) (Sex) (Civil Status) (Religion)

(Residence Address) (Residence Telephone Number)

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: Elementary High School College Post Grad Vocational
Please specify: Graduate Under Graduate

OCCUPATION : HONORARIUM:

BENEFICIARIES:
NAME DATE OF BIRTH RELATIONSHIP

1. ____________________________________________ _________________________ _________________________________

2. _____________________________________________ _________________________ _________________________________

3. ____________________________________________ _________________________ _________________________________

4. ____________________________________________ _________________________ _________________________________

5. ____________________________________________ _________________________ _________________________________

I hereby certify that the above information are true and correct to the best of my knowledge.

___________________________________________ ___________________________
(Signature over Printed Name) (Date Accomplished)

Veri ed and validated by:

___________________________________________ ___________________________
(Signature over Printed Name; Position) (Date)
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