STEP 2 Fill Out the Application Form

Lake Community Cable TV Multi-purpose Cooperative

APPLICATION FORM

Personal Information
Family Name:		First Name:		Middle Name:
Nationality:		Birth Date:		Gender:	Male Female
Civil Status:

Service Address
Home/Installation Address
Unit/House Number:		Street:		Barangay:
Municipality:		Home Owner Ship:		Residency Year:
Province:		Zip Code:		Nearest Landmark:

Pin Location

Government issued ID
Upload	Passport Driver's License SSS ID PhilHealth ID	Postal ID PRC ID Comelec ID card

Proof of Billing

Upload

Electricity Bill

Water Bill

Contact Information
Cellphone Number:		Telephone Number:		Email:
Mother's Maiden Name
Family Name:		First Name:		Middle Name:
Spouse Name
Family Name:		First Name:		Middle Name:

By providing the Information above. I certify that I have secured the permission of my secondary contact person to recieve calls for Installation activities, bill reminder, service repairs on my behalf.