Republic of the Philippines

Department of Education
REGION VIII – EASTERN VISAYAS
SCHOOLS DIVISION OF SOUTHERN LEYTE

FOR THE DIVISION PERSONNEL USE ONLY

REQUEST FORM
(Version: 11/28/2022)
Date Received:
Instructions:
1. Please write the details legibly. Time Received:
2. Follow the corresponding labels.
3. Indicate “N/A” if not applicable. Receiving Officer:
4. Kindly check () the appropriate box.
REQUESTER’S PERSONAL INFORMATION

Complete Name: ____________________________________________________________________________

First Name Middle Name Surname Name Extension

Current Position: _______________________________ _________________ Sex: Male Female

(Please indicate in full-text, do not abbreviate) Mobile Number

Place of Assignment:
_________________________________________________________________________
District Name of School (Please indicate in full-text, do not
abbreviate)

Place of Birth: ________________________________________________ Date of Birth:

__________________
City/Municipality Province (mm/dd/yyyy)

Residence Address:
__________________________________________________________________________
Barangay City/Municipality Province

REQUESTED DOCUMENT/S PURPOSE

 Service Record
 Certificate of Employment
 Others (Please Specify) ____________________________
DECLARATION
I declare that the information provided in the herein request form are true and correct to the best of my knowledge and belief.
Hence, I respectfully appeal from your good office to issue the above-requested document in my favor. Moreover, I give my
consent to the processing of the herein information including the contents of the required documents and attachments (if any)
as stipulated under the R.A. No. 10173 otherwise known as the Data Privacy Act of 2012 for legitimate and lawful purposes.

_______________________________________ _______________
Requester’s Signature Over Printed Name Date

IN CASE THE REQUEST IS FILED BY AN AUTHORIZED REPRESENTATIVE

Note: Under this transaction, both the requester and his/her authorized representative must attach a
clear photocopy of any government issued identification cards for further verification of identity.

I hereby authorize Mr./Ms. _______________________________________ to transact and/or receive on my

behalf with regards to the issuance of the above-requested document.

_______________________________________ _______________
Requester’s Signature Over Printed Name Date

FOR THE DIVISION PERSONNEL USE ONLY Received by:

Approved by: Released by:
__________________________ _______________
Signature Over Printed Name Date

Address: R. Kangleon St., Mantahan, Maasin City, Southern Leyte

Telephone No: (053) 570-2916
Email Address: southernleyte.division@deped.gov.ph Page 1 of 2
 DEPARTMENT OF EDUCATION
SCHOOLS DIVISION OF SOUTHERN LEYTE

Address: R. Kangleon St., Mantahan, Maasin City, Southern Leyte

Telephone No: (053) 570-2916
Email Address: southernleyte.division@deped.gov.ph Page 2 of 2