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DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
CITIZEN'S CHARTER SERVICE REQUEST FORM
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SERVICE TITLE: ISSUANCE OF CERTIFICATE FOR SERVICE RENDERED BY LOCAL/BARANGAY OFFICIAL FOR APPLICATION FOR CSC ELIGIBILITYREFERENCE NO.
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DATE OF REQUEST
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NAME OF CLIENT/ORGANIZATION:
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Documentary RequirementsKindly Check the documents Needed
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CONTACT DETAILS:
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1. Original/Certified True Copy of Oath of Office, or in absence of such document, provide other proofs of having been duly elected or appointed such as Election Returns and Appointment Paper
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2. Certification from the following Officials as to the inclusive dates of services rendered with Satisfactory Performance and shall include the dates and place of birth of the Barangay Official (applicant) using the applicable revised CSC Form for Elective and Appointive Officials :
a.) Punong Barangay
b.) DILG-Municipal
c.) DILG-Provincial
d.) DILG-Regional		OTHER NEEDED INFORMATION, if any:
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Last Name:Middle Name:Last Name, Ext.:
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Address:
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Position:Term of Office:
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SIGNATURE:
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3. Appointment of Barangay Treasurer/Secretary; and Barangay Resolution concurring with the appointment
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RECEIVED BY:DATE AND TIME RECEIVED
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4. Authenticated copy of Birth Certificate and Marriage Contract (if applicable)
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ENDORSED TO RESPONSIBLE OFFICER:DATE AND TIME ENDORSED
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REMARKS:Name/Unit and Designation
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ACKNOWLEDGEMENT RECEIPT
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This is to acknowledge the service/s you have requested:
REFERENCE NO.
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SERVICE TITLE:Date ReceivedExpected Date of ReleaseDate of Release in case of extension



Republic of the Philippines
DEPARMENT OF THE INTERIOR AND LOCAL GOVERNMENT

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NAME OF RESPONSIBLE OFFICER/UNIT/DESIGNATION:CONTACT DETAILS:
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OFFICE ADDRESS:
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REMARKS:
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