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AGRI Application Form

This document is a membership application form for the AGRI Party-list organization. It requests personal information such as name, address, contact details, voter registration information, and includes terms and conditions for sharing this information with the organization and government entities as required by law. Applicants must sign to confirm that all information provided is true and that they consent to their data being processed and shared as stipulated.

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Mdrrmo Maayon
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© © All Rights Reserved
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107 views1 page

AGRI Application Form

This document is a membership application form for the AGRI Party-list organization. It requests personal information such as name, address, contact details, voter registration information, and includes terms and conditions for sharing this information with the organization and government entities as required by law. Applicants must sign to confirm that all information provided is true and that they consent to their data being processed and shared as stipulated.

Uploaded by

Mdrrmo Maayon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MEMBERSHIP APPLICATION FORM Attached

AGRI PARTY-LIST 1x1


Picture
***This Form is not for Sale***
(Ang Dokumentong ito ay hindi ipinagbibili o ibinibenta.)

Control No.
New Renewal Information Update

A. Personal Information (Personal an Impormasyon)

1. Last Name (Apelyido)

2. First Name (Pangalan)

3. Middle Name (Gitnang Pangalan)

4. Suffix ("Jr. Sr. I, II, III")

5. Sex (Kasarian) 6. Birth date (Araw ng Kapanganakan) 7. Civil Status (Katayuang Civil) 8. Religion (Relihiyon)

Male (Lalake) LGBT Day (Araw) Month (Buwan) Year (Taon) Single Widowed
Female (Babae) Married Legally Separated

B. Address (Tirahan)

9 No. and Street


(Bilang at kalye)
10. City/ Municipality
(Lungsod/ Lalawigan)
11. Province (Probinsya)

12.Barangay 13.Region (Rehiyon)

C. Contact Information

14. Mobile Number - 15. Landline Number:

16. Email Address: 17. Facebook/ Messenger Name

D. Person to Contact In Case of Emergency (Detalye ng taong tatawagin sa oras ng emerhensiya)

18. Complete Name


(Pangalan at Apelyido)
19. Relationship 20. Mobile
-
(Relasyon) Number

E. Voter's Registration Information ( Impormsasyon kaugnay sa pagboto)

21.Region (Rehiyon) 22.Barangay

23. Province (Probinsya)


24. City/ Municipality
(Lungsod/ Lalawigan)
25. Country Name (If voting outside the country) :
Pangalan ng bansa kung saan bumoboto (Kung bumuboto sa labas ng bansa)
F. Remarks (Karagdagang Impormasyon)

G. Terms and Conditions (Lagyan ng (  ) and kahon kung sumasangayon)


I certify that the information given above is true and correct. (Pinapatunayan ko na ang lahat ng impormasyon na aking binigay ay totoo at tama.)

I hereby give and grant my express and informed consent to Agri Party-list, including its personal information personnel/ processor to process my personal and sensitive
personal information contained in this form and in documents submitted for my membership application to verify my identity, and to process my application; (Pinapahintulutan
ko ang AGRI Party-list kasama ang mga personal information personnel/ processor nito na iproseso ang aking personal at sensitibong impormasyon na nilalaman ng form na ito at mga
dokumentong ipinasa kasama nito para sa aking membership application para ma-beripika ang aking pagkakakilanlan, at para maproseso ang aking application)

I agree that AGRI may share, transmit, disclose and transfer said information to the government and/or other government instrumentalities for purposes of complying with
the reportorial requirements provided by law and/or regulations in relation to my membership to this organization; (Pinahihintulutan ko ang AGRI Partylist na ibigay, ibahagi o
ilipat ang aking impormasyon sa gobyerno at ibang pang mga instrumentalidad ng gobyerno bilang pagtugon ng Partylist sa mga report na kinakailangan ng batas o regulasyon kaugnay
ng aking pagiging miyembro ng partylist)

I agree to receive text messages, email, messenger communications from AGRI Partylist. (Pumapayag ako makatanggap ng SMS, Email o mensahe mula sa AGRI Partylist)

I agree to be invited by AGRI in its social media platforms. (Pumapayag ako maimbita ng AGRI sa mga social platforms)

I hereby knowingly and voluntarily acknowledge and confirm that I have been duly informed of my rights under the law particularly under the Data Privacy Act of 2021. I
hereby confirm that I have executed this form of my own volition and free will. (Pinatototohanan ko na alam ko, at boluntaryong pinapatunayan na ipinaalam sa akin ang mga
karapatan ko sa ilalim ng batas particular sa Data Privacy Act of 2021. Pinapatunayan ko na nagkusa ako na magbigay ng impromasyon sa form na ito at hindi pinilit ninuman .)

Signature over printed name Date


(Lagda at kumpletong pangalan) (Petsa ng paglagda)

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