Republic of the Philippines

Province of Nueva Vizcaya

City/Municipality of Bambang
BARANGAY CALAOCAN
~~oOo~~
Office of the Punong Barangay
Date Issued: ________________________
BPO No. ______________________

BARANGAY PROTECTION ORDER (BPO)

Name of Respondent/s : _____________________________________
Age : _____________________________________
Address : _____________________________________

ORDER
__________________________________, _________ years old, a resident of # ____________________
___________________________ Calaocan, Bambang, Nueva Vizcaya applied for a BPO
on___________________________ at the Office of the Punong Barangay under oath stating that:
“Nais ni .”

After having heard the application and the witnesses and evidences, the under signed hereby
issues this BPO ordering to immediately cease and desist from causing or threatening to cause physical
harm to ___________________________________________.

This BPO is effective for fifteen (15) days upon its issuance.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW

Hon. Christopher C. Madera

Punong Barangay

Copy received by : _________________________________

Date received : _________________________________

Served by : _________________________________

ATTESTATION
(In case the Punong Barangay is unavailable)

I hereby attest that the Punong Barangay Hon. Christopher C. Madera, was unavailable, to act
on application for Barangay Protection Order No._______ filed by _______________________ on
_______ At _______ am/pm to issue such order.

________________________________
Barangay Kagawad
(Signature over printed name)

NOT VALID WITHOUT OFFICIAL DRY SEAL