Republic of the Philippines

Attach Province of Bulacan

Logo Here City of MALOLOS
Attach Photo Here
(1 1/2 " x 1 1/2 ")
Photo should be
APPLICATION FOR MUNICIPAL FISHERFOLK REGISTRATION aquired during the last
six (6) months
Registration No.: New Registration
Registration Date: Updating
1. PERSONAL INFORMATION
Complete Name
Mr Ms Mrs
Salutation Last Name First Name Middle Name Appellation (Sr, Jr, III)
Address

Street Barangay City/Municipality Province Postal Code

Contact No. Date of Birth Place of Birth Resident of the Municipality since
(Cell Phone, Telephone) (Municipality, Province) (indicate the year)

(M M - D D - Y Y Y Y
Gender Civil Status Nationality Religion
Single
Legally Seperated Filipino
Male
___Widowed ___Others (pls. specify)
___Married
Female No. of Children On Number of Household Members
Educational Background No. of male No. of female

Elementary Vocational Post- Graduate No. of in-school No. of out of school

High School College Others (pls. specify) No of employed No of unemployed

Other Source of Income (farming) Income Value Php

Household Monthly Income
(fishing/ farm laboring)
Php Other Source of Income (non-farming) Income Value Php

Person to notify in case of emergency Contact No.(Cell Phone, Telephone)

Relationship
(First name, Last Name)
Address (Barangay, Municipality)
With Voter's Yes , ID No. CCT/4Ps Yes IP Yes SAAD Area Yes
ID Benficiary
No No No No

2. LIVELIHOOD
Main source of Income Livelihood Description (gears/species/type)
Capture Fishing Fish Vending
___Aquaculture ___Fish Processing
__Mariculture ___Others (pls. specify)
3. ORGANIZATION
Name of Organization Member Since Position/Official Designation

4. CERTIFICATION THUMBMARK
I have personally reviewed the information on this application and I certify under
penalty of perjury that to the best of my knowledge and belief the information on this
application is true and correct, and that I understand this information is subject to public
disclosure.

(Signature over printed name of Applicant) Date Accomplished

Left Right

5. FOR AUTHORIZED PERSONNEL ONLY

Reviewed by: Certified Correct by: Approved by:

(Signature over printed name) (Signature over printed name) (Signature over printed name)