Office of the Senior Citizen Affairs

Municipality of New Lucena

Date Applied_________________
Name_________________________________________________________________________
Surname
First Name
Middle name
Date of Birth___________________Age___________Sex__________CS__________________
Place of Birth__________________________________________________________________
Address_______________________________________________________________________
Educ. Attainment_______________________________________________________________
Occupation_________________________________Annual Income_______________________
Other Skills____________________________________________________________________
Family Composition
Name

Age

CS

Relationship

Occupation

Use other side of this form if necessary

Name of Association joined_______________________________________________________
Address of the Association________________________________________________________
Date of Membership_____________________________________________________________
If an officer, date elected_________________________________________________________
I certify that the above information is true and correct to the best of my knowledge and belief.
Note: This registration form shall be secured at the senior citizen OSCA and prepare 1- 1x1 picture for
OSCA ID.
________________________
Signature of Applicant
Res. Cert. No.____________
Date Issued______________
Place Issued_____________
Requirements:
A. Submit one of the following:
1. Baptismal Certificate
2. Birth Certificate
3. Voters Affidavit
4. Joint Affidavit and Certifications
5. Marriage Contract
6. Certification of Age and Date of Birth by the Punong Barangay
7. Any ID that shows, date of birth and age
B. Certificate of Waste Segregation duly signed by BEW and noted by the Punong Barangay
C. Membership fee of Php 30.00