Division: ________________________________________________________________________________

School: ____________________________________________________________________

Address: ________________________________________________________________________________

_________________________________________
Name of Organization

___________________
Date

HON. PAUL ELMER M. CLEMENTE

Deputy Ombudsman for the Visayas
Office of the Deputy Ombudsman for Visayas
M. Velez Street, Guadalupe, Cebu City

Dear Deputy Ombudsman Clemente:

Pursuant to the state policy to take positive and effective measures against graft
and corruption, there is a need to empower the country’s future leaders by enhancing
theirleadership skills, instill the values of integrity and social responsibility, and
encourage their participation in corruption prevention.

In this connection, we want to do our share by getting involved in the corruption

prevention initiatives of the Office of the Ombudsman through the Campus Integrity
Crusaders (CIC) Program.

We have the honor to apply for Accreditation as CIC Program Partner.

Enclosed are the documentary requirements enumerated in Section 5 of

Memorandum Circular No. 04, s. 2012

1) Certification as an accredited school organization and Endorsement to become

a CIC Program Partner and the Designated Adviser (page 2);
2) List of Organization’s Officers and Members (page 3 and 4);
3) Proposed Projects for School Year 20__ to 20__ (page 5)

For your Honor’s appropriate action.

Very truly yours,

___________________________
President
(Name and Signature)

(CIC Accreditation Form) Page 1 of 5

Division: ________________________________________________________________________________

School: ____________________________________________________________________

Address: ________________________________________________________________________________

_________________
Date

CERTIFICATION AND ENDORSEMENT

TO WHOM IT MAY CONCERN:

This is to certify that ______________________________________________

(Name of Organization)
isduly recognized as functional, active and accredited student organizationof this
school.

Our school strongly endorses its accreditation as Campus Integrity Crusaders

(CIC) Program Partner of the Office of the Ombudsman.

We designated _____________________________________________ as the

Adviserof the organization, who duly commits to act as such for the entire period of
accreditation andtoensure implementation of their proposed CIC activities.

____________________________________
Designated Adviser
(Name and Signature)

___________________________________
PRINCIPAL
(Name and Signature)

(CIC Accreditation Form) Page 2 of 5

Division: _________________________________________________________________________________
School: ______________________________________________________________________

Name of Organization:_____________________________________________________________________

LIST OF OFFICERS (SY 201__-201__):

Respectfully submitted: Noted:

_________________________ _________________________
President (Name and Signature) Adviser(Name and Signature)
(CIC Accreditation Form) Page 3 of 5
 Division: ________________________________________________________________________________
School: _____________________________________________________________________
Name of Organization: ___________________________________________________________________

LIST OF MEMBERS (SY 201__-201__)

Prepared by:__________________________ Noted by:_______________________

President(Name and Signature) Adviser(Name and Signature)
(CIC Accreditation Form) Page 4 of 5
 School: _______________________________________________________________________
Name of Organization: _____________________________________________________________________

Title of Current CIC Project:____________________________________________________________

ACTIVITIES OBJECTIVES TIMELINE Place to Beneficiaries PersonsRes

(Start to Finish) Implement ponsible
PROMOTING
INTEGRITY

PROMOTING
SOCIAL
RESPONSIBILITY

BATTLE CRY:

Prepared by:________________________ Noted by:_______________________

President(Name and Signature) Adviser(Name and Signature)
APPROVED:

______________________________________
Principal(Name and Signature)
(CIC Accreditation Form) Page 5 of 5