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Republic of the Philippines


COMMISSION ON EL.ltCTIONS
Manila

INSTRlICTlONS, (Read well before filling up !his form.)


1. Ale this In FlVE (5) lEGIBLE copies.
2. File this certiflfate of eandldacy wltb the law Department, COl1ElfC 11alq Office, rntramurcs, r1anila, startlng November 2.1I, 2lt09 up to
midnight of Novem~er 30, 2009. . . '. ..,
3. Alt~cb to this certlflcate the Certl!I ca t" of Party Nomination unless YOU are an .indellendentcanoldate, After midnight of November 30, 2009, no
£crtilk:ate of nomlnettcn shall be accepted.
'I, 1l!Ies such as 'Qr., Attt., Don, GinPQ, Sem"
.O<IU!, Ha~lf, Sy1!lln, Pal, SMora, "~pltan or sImilar titles are expressly protubjted. .
5. This certificate shall be .sworn' before· II notary public O[ any official autllOrl~ed to administer oath. COMClfC officials ere not authorized to
~4n:ttJlIFt~r oath. .

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1.1 last Name :L:A:N: I ,

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t: :~:: .-~: ;~: . : : : ::: :.:.: :~.: . : 5. MY DATE pF BIRTH rs .
1.2 RrsHlame :R'E:Y ". ' . . . . :9r9.H~':9':-·~::9.:~::~:
, l MWdie Neme

, _, I .AM GENERAllr.OR
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POPUI.AIlI.,Y .KNOWN P;Y
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NICKNAM15 QR5TAGIlMME
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6, MY PlACE OF BIRTH I.S :


Day Year

(Indicate only one nlckna=


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City/Mun ..•..•.. ~~ J;:.~~
Province
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.. o ~ta.MYCtV~~STATVSIS:
7.1 AM O.FFlClAU.Y NaMJrtATEP

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BY: (Attach CertlflcQleof Nomination)
Single 0 Widow/or

[:slJ Married 0 legally Separated


,9. MY R.ESIDENCEI
ADOREsSIS:
-0 Annulled I Divorced

9.2 CitY/Municipaljly

U. MT POST OffICI' AQPIm$S .fQR WCIl9" PUfU'Q§~ ~I! I \Q)yla.Vl.l 1m~~ ~ NP.9) 12,1. AM A REGlSTERE.P VOTER OF

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_ -e-, MY pemo.o O.F R~IDENCE lit THE PHJUPPlNllS IlIIlFQmlMAY :1.0, 2010 Xl>;
89Y NE!'l. ~.G .. YJ:~~(;E
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City/Mlln ~I.~.~.. qR .~J~~Y~A
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PtovinceNC~.':-: fOW\':t'lJ ..0.;r$1.~+~.
14. I AMA NA'TURAl BORN FIUPINO CI1IZEJIj.
15. I AM NOT A PSlMANEl'IT RESIDENT OF, OR IMMIGRANT TO, A FOREIGN
COUNTRY.
16.l AM WGIBLE FOR THE OFFICE 1 SEEK TO BE ELECTEDTO.
17. I WILL SUPPORT AND DEFEND THE CONSTITUTION OF THE REPUBLIC OF THE
PHILIPPINES AND W~Ll MAINTAIN TRUE FAITH AND ALLEGIANCE THeRETO. I
WIL.L OBEY THE LAWS, LEGAL ORDERS ANODfCREES PROMULGATED BY THe
OUL Y CONsTITUTED AUTMO/UTIES. I IMPose TH 061,.lGATION UPON MYS!:!LF
VOLUNTARILY, WlTHOlfT MENTALRESERVATION OR PU OSE OF EVASION.
Thum\JFrlnt