REPUBLIC OF THE PHILIPPINES

OFFICE OF THE MUNICIPAL MAYOR

CITATION TICKET
No. _______________ Date________________________

NAME: ____________________________________________________________AGE:______________________

ADDRESS:___________________________________________________________________________________

Please ne notified that on or about_______________________ o’clock of ___________________, in the Municipality

of Pandan, you have allegedly commited/omitted the following:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

Which act(s) in violation of Section ____________ of Municipal Ordinance No._______, Series of _____________
In view whereof, you are required to settle amicably your infraction of aforesaid law by paying the prescribed fine of
P________________at the Office of the Municipal Treasurer, , within ten (10) days from issuance hereof, otherwise
appropriate complaint shall be filed against you before proper agency or agencies of the government.

BY THE AUTHORITY OF THE MUNICIPAL MAYOR

____________________________________________
(Signature Over Printed Name of Apprehending Officer)

Conforme:

_________________________________________________
(Signature Over Printed Name of Person Apprehended or
Authorized Representative of Entity)