Scribd
Upload
613 views1 page

San Fernando Senior Citizen Application

This document contains an application form for senior citizens affairs in the City of San Fernando, Pampanga, Philippines. The form requests information such as the applicant's name, address, place and date of birth, emergency contact details, and requirements including a birth certificate, barangay clearance, ID photo, and proof of identification. It also includes spaces for the applicant and barangay captain signatures to certify the applicant is a bonafide resident of the barangay.

Uploaded by

Krystel Charizze Verzosa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
613 views1 page

San Fernando Senior Citizen Application

This document contains an application form for senior citizens affairs in the City of San Fernando, Pampanga, Philippines. The form requests information such as the applicant's name, address, place and date of birth, emergency contact details, and requirements including a birth certificate, barangay clearance, ID photo, and proof of identification. It also includes spaces for the applicant and barangay captain signatures to certify the applicant is a bonafide resident of the barangay.

Uploaded by

Krystel Charizze Verzosa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

City of San Fernando, (P)

City Mayor’s Office


Community Affairs Division
Office of the Senior Citizens Affairs
Control No. _________
Date: ______________

APPLICATION FORM
NAME: ___________________________ __________________________ ___________________
(Last Name) (First Name) (Middle Name)

Present Address: ___________________________________________, City of San Fernando, Pampanga


(Street/Purok/Zone/Subd.) (Barangay) (City/Municipality) (Province)

Previous Address: ______________________________________________________________________


(Street/Purok/Zone/Subd.) (Barangay) (City/Municipality) (Province)

Place of Birth: ___________________________________________ ___________________________


(City/ Municipality) (Province)

Date of Bith: __________________________ ____________________ ___________________


(Month/Day/Year) (Gender) (Civil Status)

In case of emergency, please notify: NAME: _________________________________________________


Address: ____________________________________________ Relationship: ______________________
Contact No.: ____________________________

___________________________________ REQUIREMENTS:
Signature Over Printed Name of Applicant 1. Birth Certificate (LCR/NSO/PSA)
2. Brgy. Clearance
3. 1x1 Picture
4. Any of the following: (Pls. Photo Copy)

Passport, Voter’s ID, Driver’s License,


PRC and Government Issued ID’s)

Left Thumb Mark Right Thumb Mark


ass CAD-OSCA Control No.:____________

Barangay _______________________________
City of San Fernando, Pampanga

To Whom It May Concern:

This is to certify that _____________________________________________ is a bonifide resident of


__________________________________________________, City of San Fernando, Pampanga and is
now a member of the Senior Citizens of this barangay.

This certification is being issued upon request of abovementioned person for whatever legal intent and
purpose it may serve.

Given this _____________________________________ at barangay ____________________________,


City of San Fernando, Pampanga.

___________________________ Noted by:


Signature Over Printed Name
Senior Citizens President

_________________________
Signature Over Printed Name
Barangay Captain

You might also like