BOIS Form 001 Revised 2017

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Republic of the Philippines

Department of the Interior and Local Government
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City

BARANGAY OFFICIAL’S INFORMATION SHEET

REGION : 02 CITY/MUN : Bambang

PROVINCE : Nueva Vizcaya BARANGAY :

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1,2,3,4,5,6,7) Relationship with the Appointing Authority: _______________

SK Chairperson IPMR
SK Member other Appointive Barangay Official:

TERM IN THE PRESENT POSITION _____________________________

1st 2nd 3rd

PERSONAL INFORMATION

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

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

(Residence Address) (Residence Telephone No.)

(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. I understand that for the DILG to carry out its
Mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to process my personal information, pursuant to the
Philippine Data Privacy Act of 2012

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:

CD/CLGOO/MLGOO Date
(Signature over Printed Name)