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Republic of the Philippines

Date Accomplished by Client:

CIVIL SERVICE COMMISSION

Time Accomplished by Client:

Eligibility/Exam Records Request Form (ERRF)


(Revised 01192011)

OFFICE NAME

Time Received by ESD/ERS Personnel:

REQUEST FOR ELIGIBILITY/EXAMINATION RECORDS

Initials of ESD/ERS Personnel:

Authentication of Eligibility
(attach original certificate)

Certification of Eligibility
(no/lost original certificate; attach Declaration)
PERSONAL INFORMATION (Please print.)

Others
Gender:

Name Used at the Time


of Issuance/Exam:

Civil Status:
Last Name

First Name

Middle Name

Current Name:

Presently employed?

Yes

No

If yes, please specify:

Address Used at the Time of Issuance/Exam:

Company:

Current Address:

Address:

Date of Birth:

Place of Birth:

Purpose/s of Request:

Employment

Replacement of Lost Certificate

Did Not Receive Original Certificate

Promotion

Replacement of Old/Torn/Worn-out Certificate

Others

ELIGIBILITY/EXAMINATION DATA (Please print.)


Title of Eligibility/Exam:

Rating Obtained:

Date of Issuance/Exam:

Registration/Certificate/Card/Resolution No.:

Date of Effectivity:

Place of Issuance/Exam:

Registration/Certificate/Card/Resolution Date:

Requested By:
Signature of the Eligible/Examinee

Right Thumb Print


Signature at the Time of Issuance/Exam

Contact No.

Authorized Representative
(Printed Name & Signature)

(Examinee/Eligible)

Contact No.

ACTION TAKEN
CHECKED DATA AGAINST THE ML
Book No.
Page No.
Seq./Line No.
School Code/Batch No.
Examinee/Reg. No.
Date Issued/Released:
NO AVAILABLE RECORD

CHECKED DATA AGAINST THE PSP


In Order
Photo/Picture
Signature
Date of Birth

REMARKS

REMARKS

Name/Signature/Initials:
1st Verifier:
Date:

RELEASE OF REQUEST/S
Fee:

Not In Order

O.R. No.:
Date:

2nd Verifier:
Date:

1st Validator:
Date:
Released by

Security Form No.:


2nd Validator:
Date:
Received by

Action Officer
Signature of Eligible/Representative
(Please see Guide and Checklist of Requirements at the back page.)

Date:
Time:

GUIDE IN ACCOMPLISHING THE ELIGIBILITY/EXAMINATION RECORDS REQUEST FORM (ERRF)


1. Do not leave any blank unanswered in accomplishing the request form.
2. Make sure that all information you provide are true and as written in your application for eligibility/examination.
3. Right thumb print is clear and without smudges.
CHECKLIST OF REQUIREMENTS
A. CERTIFICATION OF ELIGIBILITY (for no/lost original certificate)
1. One piece "1 inch by 1 inch" picture with name tag and signature affixed prior to having the photograph taken
* Signature must be on top of the printed name.
* The photograph should have been taken within three (3) months prior to
filing of request for Certification of Eligibility.
* Scanned, computer-generated photo/name/signature will not be accepted.
2. Properly accomplished ERRF and Declaration Form
3. Two (2) valid Identification Cards (photocopy & original)
4. Certification fee: Php100.00 per copy
5. If through a representative or if the requesting party is abroad, please refer to additional requirements below.
B. AUTHENTICATION OF ELIGIBILITY
1. Original Certificate of Eligibility or Report of Rating
2. Properly accomplished ERRF
3. Two (2) valid Identification Cards (photocopy & original)
4. Authentification fee: Php50.00 per copy
5. If through a representative or if the requesting party is abroad, please refer to additional requirements below.
Choices for Identification Card/s:
1. Company ID
2. Taxpayer's ID
3. Passport

4. Voter's ID
5. SSS ID
6. GSIS ID

7. Driver's License
8. PRC License
9. NBT License

10. NBI Clearance


11. Police Clearance

ADDITIONAL REQUIREMENTS
A. If request for certification or authentication is filed through a Representative:
1. Authorization Letter or Special Power of Attorney (SPA); and
2. One (1) valid Identification Card of the Representative.
B. If the requesting party of the certification or authentication Works/Lives Abroad:
1. Copy of Passport; and
} duly authenticated/validated by the Philippine
2. Copy of one (1) Identification Card.
} Embassy or Consular Office

Revised 01192011