Republic of the Philippines
PROVINCE OF BUKIDNON
Municipality of Impasugong
Barangay POBLACION
Office of the Punong Barangay
CLEARANCE
Name: SUBLIRAN MICHELLE O.
(SURNAME) (FIRST) (M.I)
ALLAN B. CHIU Address: Purok 8, Poblacion, Impasugong, Bukidnon
Punong Barangay
Birth Place: Lantapan, Bukidnon
KAGAWAD: Date of Birth: July 5, 1985
Rudy D. Damayan Civil Status: Single
Neil James S. Acal CTC NO. 20612455
Jesusa C. Rivera Issued on: October 10, 2017
Rolando E. Eguia Issued At:
Abner L. Garcia
Diomedes D. Tulusan Signature: Right Thumb Mark
Florentino G. Mangga
IP Representative: TO WHOM IT MAY CONCERN;
DIONESIANO S. TOMLAY
Secretary: THIS IS TO CERTIFY that the above-named person whose
SHIRLEY A. CURIBA signature and right thumb mark appeared above has requested
clearance from this office.
Treasurer:
GINES M. GANTE THIS FURTHER CERTIFIES that he/she has no derogatory records
on file and that his /her character & moral reputation in the community
are known to be good.
BRK:
SEAN GENE PHILLIP T. AUZA
THIS CLEARANCE is issued upon request of the above-named
person for loan purposes.
ISSUED this 10th day of October 2017 at
Poblacion, Impasugong, Bukidnon.
KAG. JESUSA C. RIVERA
For the Puno Officer-in-charge
Not Valid Without Official Seal Name & Designation of Issuing Officer
OR Number: 6577350 SHIRLEY A. CURIBA
Issued on: October 10, 2017 Barangay Secretary
Place of Issue Poblacion, Impasugong, Bukidnon Name & Designation of Issuing Officer
Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______
PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANC
NAME : ________________________________________ NAME : ____________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: ______________________________________ BIRTHPLACE: ______________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
TOTAL TOTAL
DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:
1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION
2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________
PUROK/SITIO LEADER PUROK/SITIO LEADE
Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______
PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANC
NAME : ________________________________________ NAME : ____________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: _______________________________________ BIRTHPLACE: ______________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
TOTAL TOTAL
DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:
1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION
2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________
PUROK/SITIO LEADER PUROK/SITIO LEADE
gong
ON
__
ARANCE
_____________
________________
FINE
MBLY
______
_____
OTAL
________
TIO LEADER
gong
ON
__
ARANCE
_____________
_______________
FINE
MBLY
______
_____
OTAL
________
TIO LEADER
Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______
PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE
NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: ______________________________________ BIRTHPLACE: ______________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
TOTAL TOTAL
DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:
1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION
2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________
PUROK/SITIO LEADER PUROK/SITIO LEADER
Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______
PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE
NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: _______________________________________ BIRTHPLACE: _____________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
TOTAL TOTAL
DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:
1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION
2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________
PUROK/SITIO LEADER PUROK/SITIO LEADER
___
_______
___
______
Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______
PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE
NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: ______________________________________ BIRTHPLACE: ______________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
TOTAL TOTAL
DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:
1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION
2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________
PUROK/SITIO LEADER PUROK/SITIO LEADER
Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______
PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE
NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: _______________________________________ BIRTHPLACE: _____________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
TOTAL TOTAL
DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:
1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION
2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________
PUROK/SITIO LEADER PUROK/SITIO LEADER
___
_______
___
______
