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KR Form- 1
KASAMBAHAY REGISTRATION FORM

INSTRUCTION: ACCOMPLISH IN TWO ( 2 ) COPIES KR NO. M i l l I I I 1 1 1

CHECK ( V ) THE APPROPRIATE BOXES (YYYY-5 Numbers. Ex. 2013-00001)

1 . PERSONAL INFORMATION

FIRST NAME MIDDLE NAME LAST NAME

EMPLOYER’S ADDRESS:
(House No. / Street / Sulxiivision/ 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 - 1 BIG 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
1 1 Elementary Undergraduate I I High School Graduate Vocational
Elementary Graduate College Undergraduate
I I High School Undergraduate I 1 College Graduate

4. WORK INFORMATION

Monthly Salary: Php

Nature of Work: I 1 General Househelp I 1 Yaya
Cook 1 1 Gardener
I 1 Laundry Person I I Others ( Pis. specify )

Employment Arrangement: I I Live- In I 1 Live-Out

Name of Employer:

5. ATTACHED DOCUMENT

I I 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
Received by:
Kasambahay Desk Officer
Date: