Document Code

FM-SP-DILG-07-01
DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
Rev. No. Eff. Date Page
CITIZEN'S CHARTER SERVICE REQUEST FORM 00 06.15.21 of 1 1

SERVICE TITLE: ISSUANCE OF CERTIFICATE FOR SERVICE RENDERED BY REFERENCE NO.

LOCAL/BARANGAY OFFICIAL FOR APPLICATION FOR CSC ELIGIBILITY DATE OF REQUEST
NAME OF CLIENT/ORGANIZATION:
Kindly Check the
Documentary Requirements documents
Needed CONTACT DETAILS:
1. Original/Certified True Copy of Oath of Office
2. Certification from the following Officials as to the inclusive dates OTHER NEEDED INFORMATION, if any:
of services rendered with Satisfactory Performance and shall include
the date and place of birth of the Barangay Official (applicant) using Last Name: Middle Name: Last Name, Ext.:
the revised CSC Form dated April 2012:
a.) Punong Barangay Address:
b.) DILG-Municipal Position: Term of Office:
c.) DILG-Provincial SIGNATURE:
d.) DILG-Regional

3. Appointment as Barangay Treasurer/Secretary Resolution duly

concurred by Barangay Treasurer/Secretary
RECEIVED BY: DATE AND TIME RECEIVED
4. Authenticated copy of Birth Certificate and Marriage Contract (if
applicable)
ENDORSED TO RESPONSIBLE OFFICER: DATE AND TIME ENDORSED
REMARKS:
Name/Unit and Designation
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ACKNOWLEDGEMENT RECEIPT
This is to acknowledge the service/s you have requested: REFERENCE NO.
SERVICE TITLE: Date Received Expected Date of Release Date of Release in case of
extension

Republic of the Philippines

DEPARMENT OF THE INTERIOR AND LOCAL GOVERNMENT
NAME OF RESPONSIBLE OFFICER/UNIT/DESIGNATION: CONTACT DETAILS:
OFFICE ADDRESS:
__________________________________________________________________
REMARKS: __________________________________________________________________
__________________________________________________________________
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REMARKS: __________________________________________________________________
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