Eligibility/Exam Records Request Form (ERRF) Republic of the Philippines Date Accomplished by Client:

(November 2010) OFFICE

OFFICE NAMENAME Time Accomplished by Client:
CIVIL
CIVIL SERVICE
SERVICE COMMISSION
COMMISSION Time Received by ESD/ERS Personnel:
REQUEST FOR ELIGIBILITY/EXAMINATION RECORDS Initials of ESD/ERS Personnel:
Certification of Eligibility Authentication of Eligibility Others (ELIGIBILITY CARD)
(no/lost original certificate) (attach original certificate) not available
PERSONAL INFORMATION (Please print. ) Gender:
Name Used at the Time Civil Status:
of Issuance/Exam: Last Name First Name Middle Name Presently employed? Yes No
Address Used at the Time of Issuance/Exam: If yes, please specify:
Current Name: Company:
Current Address: Address:
Date of Birth: Place of Birth:
Purpose/s of Request: Employment Replacement of Lost Certificate of Eligibility (COE) Did Not Obtain/Receive original COE
Promotion Replacement of Old/Torn/Soaked COE Others
ELIGIBILITY/EXAMINATION DATA (Please print.)
Title of Eligibility/Exam: Rating Obtained: Date of Effectivity:
Date of Issuance/Exam: Registration/Certificate/Card/Resolution No.:
Place of Issuance/Exam: Registration/Certificate/Card/Resolution Date:
Requested By:

Signature of the Eligible/Examinee Right Thumb Print Authorized Representative

Signature at the Time of Issuance/Exam (Printed Name & Signature)
Contact No. (Examinee/Eligible) Contact No.
Email Address:

ACTION TAKEN
CHECKED DATA AGAINST THE ML CHECKED DATA AGAINST THE PSP
Book No. Page No. Seq./Line No. In Order Not In Order
School Code/Batch No. Examinee/Reg. No. Photo/Picture
Date Issued/Released: Signature
NO AVAILABLE RECORD Date of Birth
REMARKS REMARKS
Name/Signature/Initials: Security Form No.:
1st Verifier: 2nd Verifier: 1st Validator: 2nd Validator:
Date: Date: Date: Date:
RELEASE OF REQUEST/S Released by Received by
Fee: O.R. No.: Date:
Date: Action Officer Signature of Eligible/Representative Time:

(Please see Guide and Checklist of Requirements at the back page.)

PLEASE INDICATE DESIRED NUMBER OF CERTIFICATION AND AUTHENTICATED COPY

YOU WISH TO REQUEST

Reminders:
1. Please pay via Landbank Link.Biz
Number of Copies
portal. (https://www.lbp-
CERTIFICATION: eservices.com/egps/portal/index.jsp).

AUTHENTICATION: 2. Direct Bank Transfers and/or deposits

representing payments of transactions
with CSC ROXI will no longer be
RETURN OF REQUESTED DOCUMENTS accepted.

PLEASE PUT A CHECK (√) MARK FOR COURIER SERVICE 3. For payment details of your requested
transaction/s please read the GUIDE IN
ACCOMPLISHING THE
COURIER WITHIN DAVAO CITY (P175.00) ( ) ELIGIBILITY/EXAMINATION RECORDS
REQUEST FORM (ERRF) and follow
COURIER OUTSIDE DAVAO CITY (P250.00) ( )
instructions carefully.