CITY OF BACOOR - BeGIn CEIR

First Name:*

Last Name:*

Middle Name:

Suffix:

Civil Status*

Gender:*

Birth Date:*

Cellular*

Land Line

Email:

Address

Room #:

Floor #:

Building #:*

Street Name*

Photo (2x2)*

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Barangay*

Town | City*

Province*

Region*

Others

Ethnicity

Religion

Attainment

ALLERGIES

Drug Allergy

Insect Allergy

Mold Allergy

Pollen Allergy

Food Allergy

Latex Allergy

Pet Allergy

For the proper A4 categories please click on this A4 Guide

Category*

Category ID*

ID #*

PhilHealth ID

Disability Card

Employment:

Employer Name:

Employer LGU

Profession

Other Profession:*

Emp. Addr.:

Emp. Contact:

With Comorbidity

COMORBIDITY

Hypertension

Kidney Disease

Bronchial Asthma

Cancer

HeartDiesase

Diabetes Mellitus

Immunodeficiency

Others

HISTORY

I am pregnant

I have been COVID diagnosed

Diagnostic Date:

COVID Class.:

I hereby voluntarily submit my information and that I authorise the City of BACOOR to utilize such in concern with the COVID 19 efforts. In addition, I have read and understood the privacy policy as stated in the conditions of use.

SUBMIT

A4.1	Commuter transport (land, air, and sea), including logistics Motorcycle (e.g., angkas) and tricycle drivers Car, taxi, van drivers (including jeepney, taxi/fx drivers), transport network vehicle service (TNVS) Bus drivers, train/tram operators Truck drivers and helpers (pahinante) Active seafarers, domestic or international (with recorded sea service within the last 2 years) Aircraft pilots and other associate professionals Transport conductors Travel attendants and travel stewards (includes ship stewards) Luggage porters Service station attendants (includes gasoline attendants) Cleaners and janitors in stations, terminals, and airports
A4.2	Public and private wet and dry market vendors; frontline workers in grocery, supermarkets Stall and Market Salespersons Shopkeepers (e.g., cashier, shelf fillers, baggers ... ) Retail Trade Operators and Frontliners Shop Supervisors Sorting Clerks Package Deliverers Sari-Sari Store tindero/tinder Cleaners and Janitors in markets, groceries and supermarkets
A4.3	Workers in manufacturing for food, beverage, medical and pharmaceutical products
A4.4	Frontline workers in food retail, including food service delivery Food Service Counter Attendants Waiters Restaurant Managers Fast Food Preparers Street Food Vendors Chefs, Cooks, Kitchen Helpers Food Stall ("Carinderia") workers Food home delivery Cleaners and janitors in food establishments
A4.5	Frontline workers in Financial Services in private and government Bank Tellers and Related Clerks Cashiers and Ticket Clerks Pawnbrokers, Frontliners in Remittance Centers, Bayad Centers
A4.6	Frontline workers in hotels and accommodation Hotel receptionists and concierge Cleaning and housekeeping personnel in hotels, and similar establishments Workers in hotel and accommodation not elsewhere classified (parking attendant, bellboy, usher, etc.)

COVID ELECTRONIC IMMUNIZATION RECORD REGISTRATION

A4 Category Guide