Republic of the Philippines

QUEZON CITY COUNCIL

APPLICATION FOR ACCREDITATION
(Pursuant to RA 7160 and its IRR/LGC of 1991/ SP No. 23, S-92/ SP No. 1494, S-2005/SP No. 1942, S-2009)

PART I. ORGANIZATION PROFILE

New Previously Accredited in What year?
Name of Organization/Association:

Office Address:
District: Barangay: No. of Male:
Date Organized: Members Female:
Official Email Address: Contact no/s:
PART II. REGISTERING AGENCY (Please check appropriate box)
Date Registered:
Securities and Exchange Commission Department of Labor and Employment
Cooperative Development Authority Department of Social Welfare & Development
Department of Human Settlements and Urban Development Others (Pls. Specify):
(Formerly Housing and Land Use Regulatory Board)
PART III. ORGANIZATIONAL LEVEL: (Please check applicable box)
Barangay-Based Chapter
Federation Others (Pls. Specify):
Affiliate of large NGO
(Specify name of NGO):
PART IV. PURPOSE/OBJECTIVES OF THE ORGANIZATION (Please use additional sheet if necessary)

PART V. ADVOCACY/ies/SERVICES (Please use additional sheet if necessary)

PART VI. SECTOR/GROUP REPRESENTED/SERVED (PLEASE CHECK ONE [1] ONLY):

(1) Academe/Education (14) Religious/Faith-Based
(2) Business (15) Senior Citizens
(3) Charitable/Socio-civic (16) Social Justice/Peace and Order
(4) Cooperative (17) Socio-Cultural Development Pls. SPECIFY YOUR SECTOR HERE
(5) Environment/Urban Protection/ Solid waste (18) Solo Parents ( in written form)
(6) Health and Sanitation (19) Transport/PUV Drivers/Operators/TODA
(7) Home Owners (20) Urban Farming
(8) Labor/Workers (21) Urban Poor
(9) LGBT (22) Women
(10) Livelihood/Vendors (23) Youth/Sports/Children
(11) Muslim
(12) Professional
(13) Persons with Disability
PART VII. SOURCE OF FUND
Membership Dues Fund Raising Local Contribution Others (Pls. Specify)
Local Grant Foreign Grant Foreign Donation
We hereby certify to the correctness of the above information.
Submitted by: Certified by:

THIS FORM IS
NOT FOR SALE

Chairperson/President Date accomplished Secretary

Signature over Printed Name Signature over Printed Name