PHILIPPINE INSTITUTE of REAL ESTATE SERVICE

PRACTITIONERS (PhilRES) INCORPORATED

MEMBER’S PERSONAL DATA SHEET

BROKER

APPRAISER

PERSONAL DATA CONSULTANT LAST NAME FIRST NAME MIDDLE NAME

MALE FEMALE

CITIZENSHIP CIVIL STATUS SINGLE MARRIED WIDOWED SEPARATED

DATE OF BIRTH (mm/dd/yy)

PERMANENT MAILING ADDRESS ZIP CODE

RESIDENTIAL ADDRESS ZIP CODE

PLACE OF BIRTH TELEPHONE / CELLPHONE NUMBER

SPOUSE’S NAME & CITIZENSHIP FATHER’S NAME & CITIZENSHIP MOTHER’S NAME & CITIZENSHIP

Have you ever been charged in any administrative, civil or criminal proceeding/s? No______ Yes______ if yes, what is the status of such case/s? Please attach additional sheet if necessary.

EDUCATIONAL DATA

Name of School Location Course/Degree Completed

FROM (mm/dd/yy)

TO (mm/dd/yy)

High School

College

Graduate/Post Graduate

PREVIOUS LICENSURE EXAMINATION/S TAKEN NAME OF EXAMINATION

PRC R.E.B. EXAM / SEC 20

PRC R.E.A. EXAM / SEC 20

PRC R.E.C. EXAM / SEC 20

DATE TAKEN License No. Date Issued Rating Date Renewed VERIFIED BY:

CSC (RPAO)

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EMPLOYMENT RECORD

OFFICE POSITION HELD SPECIFIC WORK/FUNCTION FROM (mm/dd/yy)

TO (mm/dd/yy)

I hereby certify that the information and statements in this application including the documents submitted in support thereof are all true and correct to my own knowledge, and that I am fully aware that any false information, statement or non-disclosure in this application and/or in the attachments thereto shall invalidate this application and render the liable for criminal prosecution and/or administrative sanction. I hereby authorize the Philippine Institute of Real Estate Service Practitioners (PhilRES) Incorporated to verify the veracity and truthfulness of all information contained herein.

APPLICANT’S SIGNATURE OVER PRINTED NAME DATE LEFT THUMB PRINT RIGHT THUMB PRINT

Subscribed and sworn to before me this _____ day of ______, _____ by the affiant exhibiting his valid Identification Card No. ______________ issued at __________ on _________________.

NOTARY PUBLIC Doc. No. _____ Page No. _____

Book No. _____ Series of 2011

MEMBER APPLICANTS DO NOT WRITE BELOW THIS LINE

MEMBERSHIP COMMITTEE OK By _________________________ Pending Reason ___________________ Date __________

CHAPTER DEV. & CHAP. AFFAIRS COMMITTEE OK By _________________________ Pending Reason ___________________ Date __________

APPROVED TO NEW LOCAL CHAPTER ____________________________ REFERREDTO LOCAL CHAPTER ___________________________

2” x 2” Most Recent

Colored Photo with complete Nametag on

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