Republic of the Philippines

Municipality of Can-avid, Eastern Samar

BARANGAY PANDOL
blgu4pandol1948@gmail.com
blgupandol

OFFICE OF THE PUNONG BARANGAY

BARANGAY CLEARANCE
TO WHOM IT MAY CONCERN:
PURSUANT to the provision of the Local Government Code, permission hereby granted to herein
applicant as follows:
NAME : _________________________________________
SEX : _________
Passport AGE : _________
BIRTHDAY : __________________________
Size BIRTHPLACE : _________________________________________
CIVIL STATUS : _________
NATIONALITY : _________

REMARKS:
This is further certified that who is known to undersigned, is a bonafide resident of Barangay Pandol,
Can-avid Eastern Samar with a good character and a law-abiding citizen and has NEITHER NO
CRIMINAL RECORD(S) IN THIS BARANGAY AS OF THIS DATE.

THIS CLEARANCE is issued upon the request of the

above-named person for whatever legal purpose this
may serve.
Signature/thumb mark of applicant
Paid under OR no.: _______________
Issued on: ________________ BSN: 2024-
Issued at: Brgy. Pandol, Can-avid, Eastern Samar
Duty Officer:
Issued by:
____________________________
MR. GENER T. CASPE
Brgy. Kagawad
Brgy. Secretary
Approved by:

HON. DOMINADOR O. GERSIN SR.

NOTE! Punong Barangay
Valid for three (3) months
Only from the date today