KR Form - 1

KASAMBAHAY REGISTRATION FORM

INSTRUCTION: ACCOMPLISH IN TWO (2) COPIES KR No.
CHECK (√) THE APPROPRIATE BOXES (YYYY-5 Nos. Ex 2013-00001)

1. PERSONAL INFORMATION

__________________ ______________________ __________________

First Name Middle Name Last Name

EMPLOYERS ADDRESS: ____________________________________________

(House No. /Street/Subdivision/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-IBIG 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
Elementary Undergraduate High School Graduate Vocational
Elementary Graduate College Undergraduate
High School Undergraduate College Graduate
4. WORK INFORMATION

Monthly Salary: P ______________

Nature of Work: General Househelp Yaya
Cook Gardener
Laundry Person Others (Pls. specify)
_____________________
Employment Arrangement: Live-in Live-Out
Name of Employer: ________________________________

5. ATTACHED DOCUMENT

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: ______________________