Republic of the Philippines

PROVINCE OF MASBATE
MUNICIPALITY OF ______________

CONSOLIDATED LIST OF LOCALLY STRANDED INDIVIDUALS (LSIs)

MEDICAL CLEARANCE
NAME APPLICANT CONTACT PLACE OF COMPLETE DESTINATION VEHICLE AND CONTACT NO. CERTIFICATION
GENDER AGE NAME OF DRIVER REMARKS
(Last, First, Middle Name) NO. ORIGIN ADDRESS LGU PLATE NO. OF DRIVER
1= YES Date of
0 = NO Issuance
1
2
3
4
5
6
7
8
9
10

Prepared by: Noted:

ROF - LSI Point Person MLGOO

LGU Task Force COVID-19 C/M DILG-OFW Desk Officer