KR Form-1

KASAMBAHAY REGISTRATION FORM

INSTRUCTION: ACCOMPLISHMENT IN TWO (2) COPIES KR NO. -

CHECK () THE APPRPRIATE BOXES (YYYY-5 Numbers. 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 : ☐ Male ☐ Female CIVIL STATUS : ☐ Single ☐ Married ☐ Widow/er ☐ Separated

AGE : DATE OF BIRTH : (MM/DD/YYYY) 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 NO. :

CONTACT PERSON

3. EDUCATIONAL INFORMATION

Highest Educational Attainment

☐ Elementary Undergraduate ☐ High School Graduate ☐ Vocational
☐ Elementary Graduate ☐ College Undergraduate
☐ High School Undergraduate ☐ College Graduate

4. WORK INFORMATION

Monthly Salary : Php

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

Employment Arrangement : ☐ Live-In ☐ Live-Out

Name of Employer :

5. ATTACHED DOCUMENT

☐ Kontrata sa Paglilingkod sa Tahanan

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

_____________________________
Signature of Kasambahay
KR Form-1

Receive by:
Kasambahay Desk Officer

Date: ____________________________