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KR Form-l
KASAMBAHAY REGISTRATION FORM

INSTRUCTION: ACCOMPLISH IN TWO (2) COPIES KR NO. ITIIJ CIIIIJ

CHECK (...J ) THE APPROPRIATEBOXES (YYYY-5Numbers. Ex. 2013-00001)

1. PERSONAL INFORMATION

FIRST NAME MIDDLE NAME LAST NAME

EMPLOYER'S ADDRESS: _
(House No. / Street/ Subdivision/ Barangay/ City or Municipality/ Province)
HOME ADDRESS:
(House No'; Street/ Subdivision/ Barangay/ City or Municipality/Province)

SEX: 0 Male 0 Female CIVIL STATUS: 0 Single 0 Married 0 Widowjer 0 Separated

AGE: DATE OF BIRTH: (MMjDDjYYYY) CONTACT NO.: _
SSS No. PAG-IBIG No. PhilHealth No. _

2. FAMILY INFORMATION
NAME OF SPOUSE: CONTACT NO. _
FATHER'S NAME: ADDRESS: _
MOTHER's NAME: ADDRESS: _
IN CASE OF EMERGENCY, CONTACT PERSON: CONTACT NO. _

3. EDUCATIONAL INFORMATION
Highest Educational Attainment
o Elementary Undergraduate
o Elementary Graduate
o High School Undergraduate
o High School Graduate D Vocational
o College Undergraduate
o College Graduate

4. WORK INFORMATION

Monthly Salary: Php _

Nature of Work: o General Househelp o Yaya
o Cook o Gardener
o
Laundry Person o Others (PIs. specify)

Employment Arrangement: OLive-In OLive-Out

Name of Employer: _

5. ATTACHED DOCUMENT

o Kontrata sa Paglilingkod sa Tahanan

I hereby certify that the above infonnation are true and correct and may be used for any
legal purpose. I further certify that my signature appearing herein is genuin~ and authentic.

Signature of Kasambahay
Received by: _
Kasambahay Desk Officer
Date: