2x2PICTURE

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Reference/Control No.:

PART I: PERSONAL INFORMATION

SURNAME

MIDDLE NAME

FIRST NAME

EXTENSION NAME

MIDDLE NAME EXTENSION NAME

SURNAME FIRST NAME

ADDRESSHOUSE/LOT/BLDG. NO. STREET/SITIO/SUBDV. BARANGAY

MUNICIPALITY/CITY PROVINCE REGION

CONTACT NUMBER:

PERSON WITH DISABILITY (PWD): □ Yes □ No

MOTHER’SMAIDEN NAME:

PLACE OF BIRTH: DATE OF BIRTH:

CIVIL STATUS:

RELIGION:

NAME OF SPOUSEIF MARRIED:

□ Single □ Married□ Widowed □ Separated

HIGHEST FORMAL EDUCATION:

□ None □ Elementary □ High School

□ Post Graduate□ Vocational □ College

HOUSEHOLD HEAD? □ Yes □ No

If no, name of household head:

Relationship:

No. of living household members:

No. of male: No. of female:

Specify ID number if yes:

Member of an Indigenous Group? □ Yes □ No

4P’s Beneficiary? □ Yes □ No

If yes, specify:

If yes, specify:

With Government ID? □ Yes □ No

Member of any Farmers Association/Cooperative? □ Yes □ No

PART II: FARM PROFILE

MAIN LIVELIHOOD □ FARMER □ FARMWORKER/LABORER □ FISHERFOLK

For farmers:

Type of Farming Activity □ Rice

□ Corn

□ Other crops,please specify:

□ Livestock,please specify:

□ Poultry,please specify:

For farmworkers: For fisherfolk:

Kind of Work

□ Land Preparation

□ Planting/Transplanting □ Cultivation □ Harvesting

□ Others, please specify:

Type of Fishing Activity

□ Fish Capture

□□

Aquaculture

Gleaning

□□

Fish Processing

Fish Vending

□ Others, please specify:

Gross Annual Income Last Year: Farming: Non-farming:

The Lending Conduit shall coordinate with the Bureau ofFisheries and Aquatic Resources (BFAR) in the issuance ofa certification that the fisherfolk-borrower under PUNLA/PLEA is registered under the Municipal FisherfolkRegistration (FishR).

RSBSA ENROLLMENT FORM ANI AT KITA

Reference/Control No.:

REGISTRY SYSTEM FOR BASIC SECTORS IN AGRICULTURE (RSBSA)

ENROLLMENT: □ New □ Existing

SEX: □ Male □ Female

Registry System for Basic Sectors in Agriculture (RSBSA)ENROLLMENT CLIENT’S COPY

THIS FORM IS NOT FOR SALE

REVISED VERSION: 09-2019

CONTACT NUMBER:

PERSON TO NOTIFY INCASE OF EMERGENCY:

FARMPARCEL

NO.

1

FARM LAND DESCRIPTION SIZE (ha)

NO. OFHEAD

(For Livestockand Poultry)

FARM TYPE**

ORGANICPRACTITIONER

(Y/N)

CROP/COMMODITY(Rice/Corn/HVC/Livestock/Poultry/

Agri-fishery)

For Livestock & Poultry(specify type of animal)

SIGNATURE ABOVE PRINTED NAME / DATECITY/MUNICIPAL AGRICULTURE OFFICE

SIGNATURE ABOVE PRINTED NAME / DATECAFC/MAFC CHAIRMAN

SIGNATURE ABOVE PRINTED NAME / DATEBARANGAY CHAIRMAN

DATE

VERIFIED TRUE AND CORRECT BY:

THUMBMARKSIGNATURE OF APPLICANTPRINTED NAME OF APPLICANT

VERIFIED TRUE AND CORRECT BY:

THIS FORM IS NOT FOR SALE

SIGNATURE ABOVE PRINTED NAME / DATE

CITY/MUNICIPAL AGRICULTURE OFFICESIGNATURE ABOVE PRINTED NAME / DATE

CAFC/MAFC CHAIRMANSIGNATURE ABOVE PRINTED NAME / DATE

BARANGAY CHAIRMAN

I hereby declare that all information indicated above are true and correct, and that they may be used by Department of Agriculture for the purposes of registration to the Registry System for Basic Sectors in Agriculture (RSBSA) and other legitimate interests of the Department pursuant to its mandates.

The collection of personal information is for documentation, planning, reporting and processing purposes in availing agricultural related interventions. Processed data shall only be shared to partner agencies for planning, reporting and other use in accordance to the mandate of the agency. This is in compliance with the Data Sharing Policy of the department. You have the right to ask for a copy of your personal data that we hold about you as well as to ask for it to be corrected if you think it is wrong. To do so, please contact <Contact Person and Contact Details>.

DATA PRIVACY POLICY

OWNERSHIP DOCUMENT * FARM TYPE **1. Certificate of Land Transfer2. Emancipation Patent3. Individual Certificate of Land Ownership Award (CLOA)4. Collective CLOA5. Co-ownership CLOA

6. Agricultural sales patent7. Homestead patent8. Free Patent9. Certificate of Title or Regular Title10. Certificate of Ancestral Domain Title11. Certificate of Ancestral Land Title12. Tax Declaration

1 - Irrigated2 - Rainfed Upland3 - Rainfed Lowland

(NOTE: not applicable to agri-fishery)

Location (Barangay & Municipality):

Total Farm Area: ___________________ha

*Ownership Document No: _______________

Registered Owner□ Others:□Tenant(Name of Land Owner: )

□

Lessee(Name of Land Owner: )

□

No. of Farm Parcels: Agrarian Reform Beneficiary (ARB): □ Yes □ No

2

Location (Barangay & Municipality):

Total Farm Area: ___________________ha

*Ownership Document No: _______________

Registered Owner□ Others:□Tenant(Name of Land Owner: )

□

Lessee(Name of Land Owner: )

□

3

Location (Barangay & Municipality):

Total Farm Area: ___________________ha

*Ownership Document No: _______________

Registered Owner□ Others:□Tenant(Name of Land Owner: )

□

Lessee(Name of Land Owner: )

□