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ANNEX C

Name Sex Age

Date of Birth Place of Birth

Citizenship Civil Status

Home Address Telephone

Mobile Fax Email

Level College

Post Graduate

Others

Office Address Telephone

Fax PSR NOMINEE INFORMATION SHEET

PERSONAL DATA

EDUCATIONAL BACKGROUND

School Year Course

BUSINESS/ EMPLOYMENT DATA

(2)

Date Signature MEMBERSHIP IN PRIVATE SECTOR ORGANIZATIONS

Name of Organization Position Period

PROJECT INVOLVEMENT

Name of Project Nature of Project Period

I hereby certify that I am available and willing to serve as private sector representative to the Regional Development Council (RDC) and that I promise to participate actively in all RDC activities if selected as private sector representative.

I further certify that I am not holding any government position, whether elective or appointive, and do not receive any remuneration from the government.

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Unduh sekarang ( PDF - 2 Halaman - 172.35 KB )

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