Republic of the Philippines

Province of Pangasinan
City of San Carlos
BARANGAY RIZAL AVENUE

OFFICE OF THE PUNONG BARANGAY

BARANGAY CERTIFICATION
This certifies that the person whose photo, signature and thumb mark appear herein is a
native and bona fide resident of this barangay. He is law abiding and peace-loving citizen
and not a member of any subversive organization. He is not accused or convicted of any
crime whatsoever, according to the record on file as of this date.

FULL NAME: ___________________________________________

ADDRESS: ___________________________________________
DATE OF BIRTH: ___________________________________________
PLACE OF BIRTH: ___________________________________________
CIVIL STATUS: ___________________________________________
SEX: ___________________________________________
NATIONALITY: ___________________________________________
PURPOSE: FOR NATIONAL ID_____________
PLACE OF ISSUE: ___________________________________________
DATE OF ISSUE: ___________________________________________

picture
1x1 Picture

Signature thumb mark

Hon. Dennis D. Fermin

Punong Barangay

Not valid without seal.