SERVICE RECORD

NAME:
(SURNAME) (GIVEN NAME) (MIDDLE NAME) (If married woman, give also maiden name)

BIRTHDATE: Tax ID #: __________________

Birthplace: GSIS BP#: __________________
First Day of Service: Employee #: __________________

This is to certify that the employee named herein above actually rendered services in this office as shown by
the service record below, each line of which is supported by appointment and other papers actually issued by this
office and approved by the authorities concerned.

SERVICE RECORD OF APPOINTMENT OFFICE/ENTITY/DIV. SEPARATION

Inclusive Dates STA./PLACE/BRANCH LEAVE ABS.
W/O PAY Date Remarks
FROM TO Designation Status Salary OF ASSIGNMENT

xxx NOTHING FOLLOWS xxx

CERTIFIED CORRECT:

*PRINCIPAL

NOTED:

ARVIN R. PURISIMA
Administrative Officer V