Republic of the Philippines

National Police Commission

PHILIPPINE NATIONAL POLICE
_______________________ POLICE PROVINCIAL OFFICE
_____________________ POLICE STATION
Address: ______________________

SAMPLE ONLY

CERTIFICATION

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that based on the Police Blotter of this Police Station,
record of the events mentioned hereunder was entered in the Log Book Blotter, to
wit:
_________________________________________________________________

BLOTTER ENTRY No :
PAGE NUMBER :
NATURE OF CASE.INCIDENT :
DATE/TIME OF OCCUREANCE :
PLACE OF OCCURRENCE :
_________________________________________________________________

FACTS OF THE CASE:

DISPOSITION : For record as requested.

ATTENDED BY : SPO1 Cardo G Dalisay

This certification is being issued upon request of ___________________ in

connection with his application foe availment of Protective Security Personnel.

Issued this ____ day of _________________, _________________,

Philippines.

For the Station Commander:

BARBIE M MANILOW
Police Senior Inspector
Chief, SIDMB

Note: Certification must be signed or noted by a commissioned officer