SWORN CERTIFICATION

( Print legibly in capital letters. No erasures. Use blue ink )

NAME OF PUPIL: _________________________________________________ GENDER: ___________

( Surname ) ( Extension Name )

( First Name )

( Middle Name )
Place of Birth : _____________________________________________
Date of Birth ( Month ,Day ,Year)
Residence Address: ________________________________________________________________________

NAME OF FATHER ( Surname ) (Extension Name)

( First Name )

( Middle Name
Father’s Occupation : _______________________________ Contact Number: _____________________
Work Place / Address: ______________________________________________________________________

NAME OF MOTHER ( Maiden ) ( Surname ) (Extension Name)

(First Name )

( Middle Name )
Mother’s Occupation: _______________________________ Contact Number : _____________________
Work Place / Address: ______________________________________________________________________

If the child is not living with parents, Please indicate:

Name of Guardian : ________________________________________ Contact Number: ________________
Present Address: _________________________________________ Relationship to the child: ___________

I, _______________________________________ of legal age, after having been duly sworn in accordance

with law, do hereby depose and state that :

1. I am the ( parent / guardian ) of this pupil.

2. I am executing this SWORN CERTIFICATION to assure authenticity and veracity of the child’s
Birth Certificate ( LCR / NSO ) submitted and that all the information contained herein are true and
correct to the best of my knowledge and belief.

3. I assume full responsibility and accountability on the validity and authenticity of the documents
submitted and I understand that I am liable to the information herein.

________________________________________________
Printed Name and Signature of Informant – ( Parent / Guardian )
Date Signed: ___________________