DIVISION OF _____________

DIVSION address
LOGO

SERVICE RECORD

Employee #:

Name: (If married woman, give also maidden name)

(Family Name) (First Name) (M.I.)

Birth: (Date herein should be checked birth or baptismal

(Date) (Place) certificate or other reliable documents)

THIS IS TO CERTIFY that the employee named above actually rendered service in this Office as shown by the service records below its line
in which is supported by appointment and other papers actually issued by this Office and approved by the authorities concerned.

Inclusive Date of Service Record of Appointment DEPED/DIVISION Leave of Separation

From To Designation Status Salary/p.a. Station/Place Branch Absence w/o Pay Date Cause

ISSUED FOR THE FOLLOWING PURPOSES: GSIS SALARY/POLICY LOAN,

PAGIBIG LOAN / ERF / REINSTATEMENT / PROMOTION / EVALUATION /
SALARY STEP INCREMENT / PPSTA / AND OTHER PRIVATE LOANS.
 Verified & Checked:

Admin. Asst. II
Issued in compliance with Executive Order No. 54, dated August 10, 1954 and in compliance with Circular No. 58, dated August 10, 1954
of the system.

CERTIFIED CORRECT:

(Date)

Admin. Asst. II