BOIS Form 001 Revised 2017

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

BARANGAY OFFICIAL’S INFORMATION SHEET

REGION : CITY/MUN :
PROVINCE : BARANGAY :

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay
Barangay Treasurer
Sangguniang Barangay
Member Barangay Secretary
Encircle Rank (1, 2, 3, 4, 5, 6, 7) Relationship with the Appointing Authority: _
SK Chairman IPMR
SK Member other Appointive Barangay Official:

TERM IN THE PRESENT POSITION: If Barangay Health Worker, check the applicable box:
Accredited/Registered by the Local Health Board
st nd rd
1 2 3 Appointed by the Barangay

PERSONAL INFORMATION
(PhilSys Card No.)

(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
ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD
ATTAINMENT: 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)