Republic of the Philippines Affix Latest COMMISSION ON ELECTIONS Photo Here Wax thy Manila ade’ NOMINEE NO. CERTIFICATE OF ACCEPTANCE a bonafide member of 1 hereby accept the nomination as its party list representative in connection with the May 13, 20f3 "Automated Synchronized National and Local Elections, and after having been sworn to in accordance with law, depose and state the following: 1. FULL NAME: (Surname/ First Name/Maternal/Maiden Name) 2. PARTY/SECTORAL ORGANIZATION/COALITIOI |. DATE OF BIRTH: PLACE OF BIRTH: AGE: GENDER (SEX) . 4. CIVIL STATUS IF MARRIED, FULL NAME OF SPOUSE: ay *(Maternal/Maiden Name) ” (4 5.1 AM A NATURAL BORN FILIPINO CITIZEN. * 6. PROFESSION OR OCCUPATIO! —_— 7. RESIDENCE (Complete/Exact Address): (House No./Street/ Municipality /City /Province) instructions "Srepace this form in twelve (12) legible copies, attach themn to the Certificate of Nornination and submit to the Clerk ofthe en CS MMELEC, Invamuros, Mena on He folowing dates: 2) For new applicant for registration, not later Uhan the last working day of March 2012 pursuant to Secs. 5 & 7, Rule 1 of Resolution No, 9966 date February 21,2012; and 1) For duly registered. partis groups of organizations, on May 31, 2012 pursuant to Secs, 2 & 3, Rule 3 of ‘Resolution No, 9366 dated February 21,2012 n relation to Resolution No, 9389 dated February 8, 2012.> 8. CONTACT NO. FOR ELECTION PURPOSES, 9. NO./OF YEARS RESIDENCE IN THE PHILIPPINES IMMEDIATELY PRECEDING THE MAY 13, 2013 AUTOMATED SYNCHRONIZED NATIONAL AND LOCAL ELECTIONS: 10. 1 AM A REGISTERED VOTER OF PRECINCT NO. | BARANGAY, CITY/MUNICIPALITY OF PROVINCE OF” 11. 1 AM ELIGIBLE for the office for which I am néminated as I possess all the legal qualifications and none of the disqualification . I will support and defend the Constitution of the Philippines, and will maintain true faith and allegiance thereto; I will obey alll the laws, Jegal orders and decrees promulgated by the duly constituted authorities of the Republic of the Philippines; and I impose this obligation upon myself voluntarily, without mental reservation or purpose of evasion. Lhereby certify that the facts stated herein are true and correct of my, own personal knowledge. 2012. (Date) . L (Printed Name & Signature of Nominee) (RIGHT HAND THUMEMARK) i . SUBSCRIBED AND SWORN to before me this, _ day of 2012, at _ affiants exhibited to me proof of his/her identity being .______ ______. issued on = at__ 4 Philippines and valid until _ (Officer Authorized to Administer Oath) oe. No. Page No. Book Na, (Asfix documentary stamp)