ANNEX “A”

BOIS Form Revised 2023

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Republic of the Philippines ID Picture
Department of the Interior and Local Government
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : CITY/MUNICIPALITY :
PROVINCE : BARANGAY :

ELECTIVE AND APPOINTIVE POSITION

(Instruction: Check the acquired position)
Punong Barangay Barangay Treasurer Barangay Secretary SK Treasurer
Sangguniang Barangay Member SK Secretary
Encircle Rank (1, 2, 3, 4, 5, 6, 7) IPMR
SK Chairperson
SK Member (Encircle Rank 1, 2, 3, 4, 5, 6, 7) Relationship with the Appointing Authority:
Other Appointive Barangay Official:
TERM IN THE PRESENT POSITION:

1st2nd3rd
If Barangay Health Worker, check the applicable box: Accredited/Regis
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 at Birth)(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 AS BARANGAY OFFICIAL:

BENEFICIARIES: (for Punong Barangay, Sangguniang Barangay Member, SK Chairperson, IPMR, Barangay Secretary, and Barangay Treasurer)
NAMEDATE OF BIRTHRELATIONSHIP

1.

2.

3.

4.
(Please use additional Sheet if necessary)

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 nec

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:

ANGELO ALEXIS C. BARROGA

CD/CLGOO/MLGOO Date
(Signature over Printed Name