KABALIKAT CIVICOM

The sole meaning of life is to serve humanity Tolstoi

Dear Sir/Madam:

We are currently updating a list of active members for inclusion in the national directory to
insure that you will be properly acknowledge by all Kabalikat Chapter nationwide. In order to guarantee
that our information with you is correct, would you please complete the form below and return it to us.

GIL DELA TORRE

Founder and National President

PLEASE PRINT

NAME: _______________________________________________________________________________
Surname First Name Middle Name
Nickname: _________________ Call Sign: ______________ Handle(s): _________________
Phone: ____________________ Beeper: _______________ Fax: ______________________
Date of Birth: ________________________________ Place of Birth: ___________________________
Civil Status: ______ Single: ______ Married: ______ Separated: Sex: ______ Blood Type: ___
Height: _________ Weight: _________ Hair: ________ Eyes: _______ Complexion: _______________
Highest Educational Attainment: __________________ School Graduated: _______________________
Course: ______________________________________ From and When: ________________________
Occupation/Profession: _________________________________________________________________
Organizations & Club of Which You are an Officer or Member:
_____________________________________________________________________________________
Home Frequency
____________ MHz Call Sign: _________________ Handle: ________________________________
Standby Frequency(ies)
1)___________ MHz Call Sign: _________________ Handle: ________________________________
2)___________ MHz Call Sign: _________________ Handle: ________________________________
3)___________ MHz Call Sign: _________________ Handle: ________________________________
Residence: __________________________________________ Phone(s): ________________________
Office: _____________________________________________ Phone(s): ________________________
Postal Address: ________________________________________________________________________
PERSON TO NOTIFY IN CASE OF EMERGENCY:
Name: _______________________________________ Relationship: ____________________________
Address: _____________________________________ Telephone: _____________________________
I hereby certify that the above declared information are true and correct.
Date: __________________
__________________________
Signature
Recommended by: Approved by:

____________________ __________________________
Chapter President National President
KABALIKAT CIVICOM
The sole meaning of life is to serve humanity Tolstoi

Dear Sir/Madam:

We are currently updating a list of active members for inclusion in the national directory to
insure that you will be properly acknowledge by all Kabalikat Chapter nationwide. In order to guarantee
that our information with you is correct, please complete the form below and return it to us.

GIL DELA TORRE

Founder and National President

PLEASE PRINT

NAME: _______________________________________________________________________________
Surname First Name Middle Name
Nickname: _________________ Call Sign: ______________ Handle(s): _________________
Phone: ____________________ Beeper: _______________ Fax: ______________________
Date of Birth: ________________________________ Place of Birth: ___________________________
Civil Status: ______ Single: ______ Married: ______ Separated: Sex: ______ Blood Type: ___
Height: _________ Weight: _________ Hair: ________ Eyes: _______ Complexion: _______________
Highest Educational Attainment: __________________ School Graduated: _______________________
Course: ______________________________________ From and When: ________________________
Occupation/Profession: _________________________________________________________________
Organizations & Club of Which You are an Officer or Member:
_____________________________________________________________________________________
Home Frequency
____________ MHz Call Sign: _________________ Handle: ________________________________
Standby Frequency(ies)
1)___________ MHz Call Sign: _________________ Handle: ________________________________
2)___________ MHz Call Sign: _________________ Handle: ________________________________
3)___________ MHz Call Sign: _________________ Handle: ________________________________
Residence: __________________________________________ Phone(s): ________________________
Office: _____________________________________________ Phone(s): ________________________
Postal Address: ________________________________________________________________________
PERSON TO NOTIFY IN CASE OF EMERGENCY:
Name: _______________________________________ Relationship: ____________________________
Address: _____________________________________ Telephone: _____________________________
I hereby certify that the above declared information are true and correct.
Date: __________________
__________________________
Signature
Approved by:

____________________
Chapter President