ANNEX A
BOIS Form 001 Revised 2020
1X1
ID Picture
Republic of the Philippines
Department of the Interior and Local Government
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : CITY/MUN :
PROVINCE : BARANGAY :
ELECTIVE AND APPOINTIVE POSITION
Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: _______________
TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:
st nd rd
1 2 3
PERSONAL INFORMATION
(Last Name) (Suffix e.g. Jr., I, II,III) (First Name) (Middle Name)
(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)
(Residence Address) (Residence Telephone No.)
(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)
HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL
Please specify: Graduate Under Graduate
OCCUPATION: HONORARIUM:
BENEFICIARIES:
NAME DATE OF BIRTH RELATIONSHIP
1.
2.
3.
4.
(Please use additional Sheet if necessary)
I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
madate they must necessarily process my personal information. Therefore, I grant my concern and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.
(Signature Over Printed Name) (Date Accomplished)
Verified and validated by:
CD/CLGOO/MLGOO Date
(Signature Over Printed Name)
