7/31/2019 PhilRES - Absentee Voting Application Form

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Petition for PhilRES Members Right to Vote in Another Voting Center

ABSENTEE VOTING APPLICATION FORM

FOR REGIONAL / SPECIAL VOTING CENTER @

_______________________________________________

18 November, 2012 Synchronized National Elections

Mother Chapter : PhilRES - _____________________ [ ] City [ ] FCM [ ] Province

Region: [ ] NCR -1 [ ] NCR -2

Region: [ ] North Luzon [ ] South Luzon

Region: [ ] Visayas [ ] Mindanao

Region: [ ] Others, pls. specify ________________________________

Requesting Member : LAST NAME - ___________________________________________

FIRST NAME - ___________________________________________

MIDDLE NAME - ______________ AIPO RECEIPT NO.: ___________

[ ] Brokers License No. : _________________________________

[ ] Appraisers License No. : (Private) __________________________

(Government) ______________________

[ ] Consultants License No.: _________________________________

Residence : ___________________________________________

Residence : ___________________________________________

Mobile Numbers: ___________________________________________

E-mail Address : ___________________________________________

Reason for Request : ___________________________________________________________

___________________________________________________________

Members Signature : __________________________________ Date: _________________

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NATIONAL COMELEC APPROVALI hereby certify that above member is

[ ] Eligible [ ] Not Eligible reason: __________________________________________

to receive an Absentee Ballot to be transmitted to above voting center. To be signed by Chairman with

concurrence of two (2) regular members.

___________________________ ___________________________ ___________________________