Council of Leaders Nomination Form

Republic of the Philippines BANGSAMORO AUTONOMOUS REGION IN MUSLIM MINDANAO OFFICE OF THE CHIEF MINISTER NOMINATION FORM Call for Nominations FOR COMMUNITY AND SECTORAL REPRESENTATIVE SEAT (Passport Size Photo) IN THE COUNCIL OF LEADERS Here *Instructions: Print legibly. Check the box that corresponds to your answer. Indicate N/A if not applicable. COMMUNITY SECTORAL  Traditional Leaders  Professionals  Non-Moro Indigenous Communities  Business  Women  Private Educational Institutions  Settler Communities  Labor  Ulama  Farmers  Youth  Bangsamoro Communities outside BARMM A. Personal Information Name: (Last Name, First Name, Middle Name) Date of Birth: (mm/dd/yyyy) Residence Address: Place of Birth: Contact Number: E-mail Address: B. Nominator Name of Nominator: (Last Name, First Name, Middle Name) Registered Name of Association: Position: Association’s Address: Contact Details: E-mail Address: C. Oath of Intent I oath to be ready, willing, and able to participate in any and all activities of the Council. I oath to uphold and honor the responsibilities that may be assigned to me without any reservation or purpose of evasion. D. Certification We attest to the truthfulness and veracity of all the facts contained herein and authorize the use of these information for the nomination. We understand that the Screening Committee will validate the accuracy of the information contained in this form and grant our consent to the conduct of a background investigation. Any misinterpretation by the signatories shall be a ground for automatic disqualification of the nominee. We solemnly signify that the herein named nominee is ready, willing, and able to participate in any and all activities of the Council without any reservation or purpose of evasion. Printed Signature: _________________________ ________________________ NOMINEE NOMINATOR