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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
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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 date and place of birth of the Barangay Official (applicant) using the revised CSC Form dated April 2012:
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 as Barangay Treasurer/Secretary Resolution duly concurred by Barangay Treasurer/Secretary
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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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Name/Unit and Designation
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REMARKS:
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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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