(Provincial Investigation & Detective Management Section)

File Nr: 2012-A-__ ______________ (Date)

Republic of the Philippines NATIONAL POLICE COMMISSION PHILIPPINE NATIONAL POLICE NORTHERN SAMAR POLICE PROVINCIAL OFFICE Camp Carlos Delgado, Catarman, Northern Samar

CLEARANCE
TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that _______________________________________, _______

(First Name) (Middle Name) (Last Name) (Civil Status)(Age) (Birth date) (Birthplace)

_______, ___ years of age, who was born on _____________, at ________________________

(Address)

(Citizenship)

presently residing at____________________________________, whose signature, picture and thumb mark appears here on, has undergone RECORD CHECK conducted by this office on its files. Findings: Purpose: Criminal or Derogatory Records on file as of this date. ________________ Prepared/Record Checked by: ____________________________ Police Officer ___ Investigator Verified by:

____________________ (Signature)

CTC Nr Issued on Issued at

: ______________ : ______________ : ______________

EUSEBIO DIOLATA ALCERA JR Police Chief Inspector Chief, PIDMS THUMBMARK

Ceritified thru Xerox Copy From the Original PCINSP EUSEBIO DIOLATA ALCERA, JR. C, PIDMS

Left Right (Note: This PNP Clearance shall automatically be cancelled if applicant be found with derogatory records during the conduct of Complete Background Investigation. Valid within 90 days from date of issue.)

Certified thru Xerox Copy from the Original PCINSP EUSEBIO DIOLATA ALCERA, JR. C, PIDMS