DATE:

SIR/MAAM:

This is to authorize, ________________________________________, to request and receive in my

behalf, the copy of my authenticated PSA Birth Certificate at PSA Davao City with the following details:

FULL NAME:____________________________________________________________________

DATE OF BIRTH:_________________________________________________________________

PLACE OF BIRTH:________________________________________________________________

NAME OF FATHER:_______________________________________________________________

NAME OF MOTHER:______________________________________________________________

NUMBER OF COPIES:_____________________________________________________________

PURPOSE:______________________________________________________________________

I understand that the documents I requested is covered by Republic Act No. 10173 of the Data Privacy
Act of 2012 and I have given my full consent in releasing the requested document to my representative.

Thank you,

__________________________________

Signature over Printed Name