..

Republic ofthe Philippines

COMMISSION ON ELECTrO
M.1IIila

INSTRUCTIONS: (Read wen before filling up this form.)

1. F;le th;5 In FIVE (5) LEGIBLEcones.
2. Fife this ceruncete of candidacy with the Law Departme.nt. COP-1ELECMain Office, to trarourcs, r+e ntta, 5lartino November 20. 2009 up to
midnight of November 30, 2009. \
3. Attach to thls certificate the Certificate or Party NominatIon unless you are an independent candidate. After midnight of November 30. 2009. no
certmcete of nomination shall be accepted.
4. Titles such as 'Dr•• Atty., Don, Ginoo. Senor, Datu, Hadji, Sultan, Bai, Senora, Kapitan or similar titles are expressly prohlblted.
S. This certtffcate shall be sworn before ~ notary public o.r,any official authorized to administer oath. COMElEC orriclafs are not authorized to
administeroath. .,

IX] Male DFemale .43

1:1 L2IstName
·.i\qj~TA .
:J.R~·NEREUS······-··' , . 5. MY DATE OF BIRrn 15:
1.2. ArstName
>-' .'> .... ~.... ,: .. --.:..... -.~-..
:0.'5"-:14 ':_;1966
1.3 Middle Name
. .......
..
',' . ::.-
.::::; ;'.--:
:'~.::>:::.:::.::
r-tonth 0"Y veer
:.OtAIVAR: 6. MY PLACE OF B~JH IS ;,.."
2.1 AM GENERALLY
(Indicate only coe nickname
OR POPULARLY
or sreqeneme)
KNOWN BYTHE NICKNAME ORSTAGENAME
C;ty/Mun MANULO.r ORTICH
:NERIC······.····
.. "
Province BUKIDNON'
~--------~~ ..
~'~.~.~'.~.~'~.~
..
~..
~.~'~.~~~~--~~~~~~~~~--~~~~~~--~~48.MYCIVrlSTATUSIS:
D Single 0 WtdfYov/er

Political Pa [XJ Married 0 Legally Separated

9. MY RESIDENCE!
ADDRESS IS: 9.1 Province . BUKIDNON o Annulled I Divorced

9.2 Citr/r-funlcipality 9.3 Barangay Full ~.' 't'H'er.tIRA¥JE

:~oLci FORTIQ( ~WAN""'" 10. MY PROFESSION OR
.... '.. -
9.4 House No.1 Street I Subdivision OCCUPATION IS :
... :ACostA:· 'FARMS';":' PROFESSOR/TEACHER
11. MY POST OFFICE ADDRESS FOR ELECTION PURPOSES IS: (eoi,1d be the same as No.9) 12. I AM A 15tff2~D VOTER OF

.. ~~~., .. M.Al'i()~Q.F()~Wr.gr,..13tJIZ]J)NON. Precinct

69Y PUROK. 3,. T.ANKUL..A.N

13. MY PERIOD OF RESIDENCE IN THE PHIUPPINES
.. ,....
BEFORE ~lAY 10, Z010 IS:
:
Oly/Mun MANOLO. FORrICH
: 0: 6: No. of HontllS
Province BUKIDNON· ...
-------------
14. I AM A NAllJRAl BORN FIUPINO anZEN.
b tUUMblllttUT .
, ,
15. IA~l NOT A PERMANENT RESIDENT OF, OR IMMIGRANT TO, A FORElGN
COUNTRY ..
16.1 AM EUGIBlE FOR THE OFFICE J SEEK TO BE ELECTED TO.
17. I WILL SUPPORT A!'ID DEFEND THE CONSTITUTION OF THE REPUBLIC OF THE
PHILIPPINES AND WILL MAINTAIN TRUE FAITH AND ALLEGIANCE THERETO. I
WILL 'OBEY THE lAWS, LEGAL ORDERS AND DECREES PROMULGATED BY THE
DULY CONSTITUTED AUTHORITIES. I IMPOSE THIS OBLIGATION UPON MYSELF
VOLUNTARILY, WITHOUT MENTAL RESERVATION OR PURPOSE OF EVASION.

Signature of Candtdate Ovr.=rPrlnttd.Nam'!

OATH
SUBSCRIBED AND SWORN to before me this __ day of November. 2009, at , affiant exhibiting to me his/her
c'TC{Identification card No. Issued by : . On : --'- _

Doc. No. 111'f i

pageNO'~;
Book No. ,;;.r ; (Officer Authorized to Administer Oath)
sertes of 2005