Republic of the Philippines

Department of the Interior and Local Government

Province of ______________
City of ______________
BARANGAY __________________

Registration Form Annex A

(Locally Stranded Individual)

*Last Name: *First Name: *Middle Name: Suffix:

*Gender: *Complete Address: Region, *Contact Number: *Age:

Male Female Province, City/Mun, Brgy

*Occupation: **Emergency Contact Person *Origin LGU: *Date of Travel

and Contact Number: Region, Province, City/Mun, Brgy to Residence:

*Destination LGU: **Vehicle: **Driver’s Name and *Date of Travel

Region, Province, City/Mun, Private Government Contact Number: to Residence:
Brgy

Medical Clearance Issued by the City/Municipal
Health Office:
Yes, Date of Issuance: __________________
No, Reason: __________________________
A Medical Clearance Certification issued by the City/Municipal
Health Office based on the following conditions:
 That the LSI is neither a contact, suspect or probable or
confirmed COVID-19 case; and
 That the LSI completed a 14-day quarantine based on the
quarantine standards set by the DOH; or
 That LSI confirmed as a COVID-19 case was tested
negative through RT-PCR twice.

Note:
* - Mandatory Field
** - If available
Underlined items will be accomplished by the DILG City/Municipal LSI Help Desk
 Republic of the Philippines
Department of the Interior and Local Government
Province of _______________
City of _____________________
BARANGAY ________________
OFFICE OF THE PUNONG BARANGAY

CERTIFICATION

TO WHOM IT MAY CONCERN:

This is to certify that Mr./Mrs./Ms_________________________________________,

__________, years old, _________________, presently residing
at__________________________________, Barangay ____________________ city of
________________________ during ECQ and EECQ.

Further, that the above named-person is not listed as SUSPECTED, PROBABLE or

CONFIRMED case of Covid 19 in this Barangay.

This certification is issued upon the request of Mr./Mrs./Ms.

__________________________________, for _________________________________________.

Issued this _______ day of ___________, 2020 at the Office of the Punong Barangay

.
 Republic of the Philippines
Department of the Interior and Local Government
Province of __________
City of ____________
BARANGAY _______________
OFFICE OF THE PUNONG BARANGAY

CERTIFICATION

TO WHOM IT MAY CONCERN:

This is to certify that Mr./Mrs./Ms. ____________________________________,

________ years old, single/married/widow, Filipino is a bonafide resident of
__________________________________

I further certify that our barangay has an available COMMUNITY ISOLATION

FACILITY that can accommodate Mr./Mrs./Ms.
_________________________________ when he/she return to this barangay from
____________________________. And as a returning resident he/she shall be
immediately placed under quarantine for Fourteen (14) days in our designated
COMMUNITY ISOLATION FACILITY from the time he/she enters the territorial
jurisdiction of this barangay as mandated by pertinent local and national government rules
and regulations.

This certification is being issued upon the request of

_________________________________ for whatever legal purpose/s it may serve best.

Given this ________ day of __________, 2020 at the Office of the Punong
Barangay,