CEF Series of 2022 Poge -I

i:

Republic of the Philippines
COMhIISSION ON ELECTIONS
Intranmros, Manila
O I signiff and mnfirm my intention to undergo the process of voter registration
tt8 years old aILd qbovel
(} I signify and confirm rny intention to undergo the process of voter regiitration in
the Katipunan ng Kabataan (15 to 17 years old)

Instruction: Fill-in completely and legibly the appropriate spares and check appropriate clroice/s in ovals.

APPLIGATION FOR REGISTRATION lnccomplish Personal lnformation atthe back)

Note: (For Applicant with existing Registration Records)

OmpucATroN FoR TRANSFER oF REGrsrRATroN REcoRD

C) within the same City/MunicipalitlDistrict.
O frOm another City/Municipality/District (Accornplish Personal lnformation at the back).
O from foreign post to local OEO other than original place of registration.
t, Fitipino, born on , a duly regisfered voter in:
O Precincf No. , Barangay Cfty/Anunicipality of Province of
(for loca,l voter)

O foreign post located in , Country of

ffor overseas voter)
My New Residence is:
House No. & Street
Barangay City/Municipality/District_Province_
I have resided in my new residence for _ years and for _ months.

APPLICATION FOR REACTIVATION OF REGISTRATION RECORD

Reason for l),eactivation:

1. Sentenced by final judgment to suffer imprisonment for not less than one (1) year;
2. Convicted by finaljudgment of a crime involving disloyalty to the duly constituted government, etc;
3. Declared by competent authority to be insane or incompetent;
4. Failed to vote in two (2) successive preceding regular elections;
5. Loss of Filipino citizenship;
6. Exclusion by a court order; or
7. Failure to Validate
That said ground no /onger exr.sfs, as evidenced by the attached certification/order of the court {in cases of 7,2,3,5, and 6).

APPLICATION FOR CHANGE OF NAME DUE TO MARRIAGE OR COURT ORDER/CORRECTION OF ENTRIES

IN THE VOTERS' REGISTRATION RECORD
(Aftach required suppofting documentrs such as Gertified Copy or Certificate of Couft Order or Certificate of Live Birth, and othem)

Present Data/lnformation:
N ew/Corrected Data/l nform ation

APPLICATION FOR INCLUSION OF RECORDS IN THE BOOK OF VOTERS / REINSTATEMENT OF NAME IN

THE LIST OF VOTERS
C) Reinstatement of records due to transfer from foreign post to same local City/MunicipalitylDistrict.
() lnclusion of VRR in the precinct book of voters.
() Reinstatement of the name of the registered voter which has been omitted in the list of voters.
I do hereby request that my name which has been omitted in the list of voters/my registration record which has not been
included in the precinct book of voters of Precinct No. _,
be reinstated/included therein. The said reinstatement of
name/inclusion of registration record is necessary and valid.

lNWlTNEsswHEREoF,lhereuntoaffixmysignaturethis-dayof,20-at-,
Province of _, Philippines.

Signature above printed name

SUBSCRIBED AND SWORN to before me on the above date

EO/Ad ministering Officer

 2

Application No. Precinct No.

USE

Jl ll co
Part 1 PERSONAL INFORMATION ( To be filted out
lndigenous
NAME llliterate
9rff,r, lf any
Senior Citizen
Last {Ex: Jr.,5r.,lll)
Person with Disability
First
O Physical O Non-manifest O visual
O Speech O Haru of Hearing/ O tvtultiple
Middle deaf Disabilities

RESIDENCE/ADDRESS Province O Assistor O VisualAssistance

o communication .Assistance O None

Senior
Nais mo bang bumoto sa unang palapag,/ground floor
(Accessible Polling Place) sa araw ng eleksyon?
House No. / Street () vEs
Cftfren, or fPs:

:: Birth Assistor's
C]TIZENSHIP i iev Naturalized Reacquired

naturulhedheocquhed, stote dote ol mturollzotton/reacqukttlon and Certifiete Number ol nattrdlization/order ol opprowl ol rcacqukition) sEx Male [--l r"rnrt"

I
( t
Certificate No. /Order of Approval OF
Date of Natu ralization/ Year
tVlonth
Reacqu isition PIACE OF BIRTH

of-Years No. gf Monthq No. o,f Ye?F City/Municipality

PERIOD OF RESIDENCE No.
:.-d..-E-: :c-::*: :"""-----

ln the CitylMun i ; i
!;z::! : , ; lnthePhilippinesi i i Province

PROFESSTON/ PARENT,S NAME

Contact No.: E-Mail Address:
OCCTIPATION
Father Name
CNIL STATUS Single Widowler
Married Name of lf Marrled f] t-egally Separated

PART 2 OATH, NOTICE and CONSENT (REGULAR ) OATH, NOTICE and CONSENT ( KATIPUNAN NG KABATAAN )

I do solemnly swear that the staternents I do solemnly swear the above statements regarding my person are true and correct; that I possess all
regarding my person are true and correct; that I possess all the qualifications and none of the disqualifications of a voter of Katipunan ng Kabataan; that I arn:
the qualifications and none of the disqualifications of a voter; tr not registered in any precinct
and that lam: E] registered in a precinct of another City/tlunicipality/District in the Philippines
E not registered in any precinct; and that I have reviewed the entries encoded in the VRS and I confirm that the same are correct, accurate and
f] registered in a precinct of another consistent with the information I supplied in this application form. Moreover, by affixing my siBnature below, I
City/ndunicipalitylDistrict in the Philippines authorize and give my consent to the Commission on Elections and the concerned Election Registration Board to
and that I have reviewed the entries encoded in the VRS and I
collect and process the personal data I supplied herein for purposes of voter's registration and elections, and for
confirm that the same are correct, accurate and consistent
other purposes and allowable disclosures under B.P. 81g.881, R.A. No. 8189, 10173 and 10367, and 10742 and the
with the information I supplied in this application form.
relevant resolutions €f the Commission on Elections. Furthermore, I understahd that when I reach eighteen (18)
Further, by affixing my signature below, I authorize and give
years of age, the personal data I supplied hereln will be further processed by the Commission on Elections, and
rny consent to the Commission on Elections and the
upon approval by the Election Registration Board, will be inciuded in and consolidated with the database ofvoters
concerned Election Registration Board to collect and process
who are at least eighteen {18} years of age for purposes of subsequent elections and for other lawful purposes and
the personal data I supplied herein for purposes of voter
registration and elections, and for other purposes and allowable disclosures mentioned above, to which further processing and hs purposes I

allowable disclosures under B.P. Blg. 881, R.A. No. 8189, f] give my consent fldo not give my consent

LALB and 10357, and the relevant Resolutions of the and that when I reach thirty one 131) years of age, my personal data in the Katipunan ng Kabataan database will be
Commission on deleted

Date
ROLLED THUMBPRINTS / SpTOMEN SIGNATURES

Applicant 2
(Signatureffhurnbmark above Printed N ame)

E lection Officer/Admi nistering Officer 3

above Printed

Part 3 ACTION BY THE ELECTION REGISTRATION BOARD

With Precinct Assignment No.
Month Day Year Beason for disapproval

Mernber Chairperson Member

(Signature above Printed Name) (Signature above Printed Name)
tsignature above Printed Name)
>

filled out by Election Afficer)

{i,
Part 4 VOTER'S IDENTIFICATION NUMBER /Io be
Part I Part ll Part lll

Proy Csok City/Mun/Dist Code Precinct Assignment ilrlrsh Ita{t Yeat Name Code/ Eirth Code

Type of Application ACKN OWLEDG EM ENT RECE IPT

O Registration Q transfer with Reastivation
your application. Your
to
O rransfer O Ctl.nge of Name/Correction of Entry
for ApprovallDisapproval by the Election Registration
application is subject
O R*..tivation O n*instatement/l nclusion Board (ERB). You need not appear in the ERB hearing unless required
for through a written notice.
Suffrr, lt any
Last lEr: lr.,St.,llll Date of ERB Hearing

First