REVISED VERSION: 09-2019
ANI AT KITA
2x2
PICTURE
RSBSA ENROLLMENT FORM
REGISTRY SYSTEM FOR BASIC SECTORS IN AGRICULTURE (RSBSA)
□ New
ENROLLMENT:
PHOTO TAKEN
WITHIN 6 MONTHS
□ Existing
Reference/Control No.:
PART I: PERSONAL INFORMATION
SURNAME
FIRST NAME
MIDDLE NAME
□ Male
SEX:
EXTENSION NAME
□ Female
ADDRESS
HOUSE/LOT/BLDG. NO.
STREET/SITIO/SUBDV.
BARANGAY
MUNICIPALITY/CITY
PROVINCE
REGION
HIGHEST FORMAL EDUCATION:
CONTACT NUMBER:
PLACE OF BIRTH:
DATE OF BIRTH:
RELIGION:
CIVIL STATUS:
NAME OF SPOUSE
IF MARRIED:
□ Single
□ Widowed
□ Married
□ Separated
□ None
□ Elementary
□ High School
□ Vocational
□ College
□ Post Graduate
PERSON WITH DISABILITY (PWD):
□ Yes
□ No
4P’s Beneficiary?
□ Yes
□ Yes
□ No
□ No
Member of an Indigenous Group?
If yes, specify:
□ Yes
With Government ID?
MOTHER’S
MAIDEN NAME:
HOUSEHOLD HEAD?
□ Yes
□ No
Specify ID number if yes:
□ No
Member of any Farmers Association/Cooperative?
If no, name of household head:
□ Yes □ No
If yes, specify:
Relationship:
PERSON TO NOTIFY IN
CASE OF EMERGENCY:
No. of living household members:
No. of male:
CONTACT NUMBER:
No. of female:
PART II: FARM PROFILE
□
MAIN LIVELIHOOD
□
FARMER
For farmers:
Kind of Work
□ Rice
□ Land Preparation
□ Planting/Transplanting
□ Cultivation
□ Harvesting
□ Others, please specify:
□ Corn
□ Other crops,
please specify:
□ Livestock,
please specify:
The Lending Conduit shall coordinate with the Bureau of
Fisheries and Aquatic Resources (BFAR) in the issuance of
a certification that the fisherfolk-borrower under PUNLA/
PLEA is registered under the Municipal Fisherfolk
Registration (FishR).
Type of Fishing Activity
□ Fish Processing
□ Fish Capture
□ Aquaculture
□ Fish Vending
□ Gleaning
□ Others, please specify:
Poultry,
please specify:
Gross Annual Income Last Year:
FISHERFOLK
For fisherfolk:
For farmworkers:
Type of Farming Activity
□
□
FARMWORKER/LABORER
Farming:
Non-farming:
Registry System for Basic Sectors in Agriculture (RSBSA)
ENROLLMENT CLIENT’S COPY
Reference/Control No.:
SURNAME
MIDDLE NAME
FIRST NAME
EXTENSION NAME
THIS FORM IS NOT FOR SALE
No. of Farm Parcels:
FARM
PARCEL
NO.
□ Yes
Agrarian Reform Beneficiary (ARB):
CROP/COMMODITY
(Rice/Corn/HVC/
Livestock/Poultry/
Agri-fishery)
FARM LAND DESCRIPTION
SIZE (ha)
For Livestock & Poultry
(specify type of animal)
NO. OF
HEAD
(For Livestock
and Poultry)
□ No
FARM TYPE
**
ORGANIC
PRACTITIONER
(Y/N)
Location (Barangay & Municipality):
Total Farm Area: ___________________ha
1
*Ownership Document No: _______________
□
□
Registered Owner
Tenant
(Name of Land Owner:
□
)
□
Lessee
(Name of Land Owner:
)
Others:
Location (Barangay & Municipality):
Total Farm Area: ___________________ha
2
*Ownership Document No: _______________
□
□
Registered Owner
Tenant
(Name of Land Owner:
□
)
□
Lessee
(Name of Land Owner:
)
Others:
Location (Barangay & Municipality):
Total Farm Area: ___________________ha
3
*Ownership Document No: _______________
□
□
Registered Owner
Tenant
(Name of Land Owner:
□
)
□
Lessee
(Name of Land Owner:
)
Others:
OWNERSHIP DOCUMENT *
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Certificate of Land Transfer
Emancipation Patent
Individual Certificate of Land
Ownership Award (CLOA)
Collective CLOA
Co-ownership CLOA
Agricultural sales patent
Homestead patent
Free Patent
Certificate of Title or Regular Title
Certificate of Ancestral Domain Title
Certificate of Ancestral Land Title
Tax Declaration
FARM TYPE **
1 - Irrigated
2 - Rainfed Upland
3 - Rainfed Lowland
(NOTE: not applicable to agri-fishery)
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.
DATE
PRINTED NAME OF APPLICANT
SIGNATURE OF APPLICANT
THUMBMARK
VERIFIED TRUE AND CORRECT BY:
SIGNATURE ABOVE PRINTED NAME / DATE
BARANGAY CHAIRMAN
SIGNATURE ABOVE PRINTED NAME / DATE
CITY/MUNICIPAL AGRICULTURE OFFICE
SIGNATURE ABOVE PRINTED NAME / DATE
CAFC/MAFC CHAIRMAN
DATA PRIVACY POLICY
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>.
THIS FORM IS NOT FOR SALE
VERIFIED TRUE AND CORRECT BY:
SIGNATURE ABOVE PRINTED NAME / DATE
BARANGAY CHAIRMAN
SIGNATURE ABOVE PRINTED NAME / DATE
CITY/MUNICIPAL AGRICULTURE OFFICE
SIGNATURE ABOVE PRINTED NAME / DATE
CAFC/MAFC CHAIRMAN