SERVICE RECORD
NAME: (If married woman, give also full maiden name)
(Last) (First) (Middle)
BIRTH:
(Data herein should be checked from birth or baptismal
Date Place certificate or some other reliable documents)
This is to certify that the employee name herein above actually rendered services in this office as showm by the service record below, each line of
which is supported by appointment.and other paper actually issued by this Office and approved by the authority/authorities concerned:
SERVICE RECORD OF APPOINTMENT OFFICE ENTITY/DIVISION SEPARATION
(Inclusive Dates) Status Salary Station/Place Branch L/VASS Date Cause
Designation
From To (1) (2) of Assignment (3) w/o pay (4)
0
Issued in compliance with Executive Order No. 54 dated August 10, 1954, and in accordance with Circular No. 58, dated August 10, 1954, of the
System.
Prepared by:
CERTIFIED CORRECT: