Republic of the Philippines

CITY HEALTH DEPARTMENT

Puerto Princesa City

CERTIFICATION ON DISABILITY

This is to certify that ________________________________________, resident of

__________________________________________________________________________, province of
Palawan in the Region of MIMAROPA, had voluntarily submitted herself/himself to this facility/clinic/office with
the regards to the nature of disability due to the functional limitation currently experience by the rein patient.

Base on the personal interview and medical assessment conducted by herein physician, the patient has
____________________________________________________________________________ accompanied by
Diagnosis

_________________________________________________________________________________________
Health Condition

which results to difficulty in (e.g. walking, seeing) and therefore considered as person with
__________________________________________________ as classified by the National Council on Disability
Type of Disability

Affairs (NCDA) Board Resolution No.1, Series of 2016.

Thus, certification is issued on ___________________________________ at place

________________________________________________ in compliance with the requirement in the issuance
of Identification Card (ID) for the twenty percent (20%) discounts for persons with Disabilities mandated by the
Republic Act No. 9442 or Magna Carta for Persons with Disabilities.

Signed:

____________________________
Name of Physician
____________________________
License Number