Republic of the Philippines

COMMISSION ON ELECTIONS Intramuros, Manila

Attach 2 x 2

ID Photo

INFORMATION SHEET

(Please type or print)

LOCAL MEDIA

NATIONAL AND LOCAL ELECTIONS

MAY 9, 2016

Name: _________________________________________________ Citizenship: _________________

(Surname) (Given) (Middle)

Date of Birth: ________________________________ Place of Birth: __________________________

Status: ______________

Residence: ___________________________________________ Tel. No.: ______________________

(City)

___________________________________________ Cel. No: ______________________

(Province)

Position/Designation: _________________________________________________________________

Organization/Agency: ________________________________________________________________

Name of Editor/Station Manager: _______________________________________________________

Business address: ____________________________________________________________________

____________________________________________________________________

Tel. Nos.: __________________________________________________________________________

Place to be Visited: __________________________________________________________________

__________________________________________________________________

_______________________

(Signature)

Requirements:

1. Endorsement letter from the newspaper, television or radio station employing the applicant.

(Editor/Station Manager)

2. 2 pcs. 2” x 2” ID photo