Document Referece Code:

SDOIC-01B3-FR-002

Document Title:
REQUEST SLIP
Effectivity Date: Revision No.
Schools Division Office of Imus City Sep-09-2020 05

Date & Time: September 7, 2022 No.

Please check the box of the document/s you are requesting and specify

Service Record Performance Indicator

Certificate of Employment NAT Result
Indorsement Teacher's Data
Travel Order Others LIS Concern
School's Data _________________________________________

NAME OF REQUESTING PARTY (please write legibly)

Requestee: Lagamo Judith Espina
Surname First Name Middle Name
Office/School: GPGSHS Designation:
Employee No. (If any): Date Hired:
Purpose of Request: LIS concerns Contact No.:
Email Address: ______________________________

JUDITH E. LAGAMO
Signature over Printed Name Authorized Representative
Signature over Printed Name
(Must be duly authorize in writing. Please attach authorization letter)

The information provided in this request slip are treated as official data and are solely for status updating of requested documents by the requestee.
SDO Imus City (SDOIC) uphold the thrust and guidelines set in RA 10173 or the Data Privacy Act of 2012
DOCUMENT MANAGEMENT
Referred to SDS:
Date Received: Received by:

Routed to: ASDS ADMIN FINANCE ICT SGOD CID

( ) Urgent ( ) Defer ( ) Revise/Modify ( ) Prepare

( ) Comply ( ) Inform/Disseminate ( ) Note & File ____ Memorandum ____ Travel Order
( ) Verify ( ) Reproduce ( ) Recommend ____ Advisory ____ Cash Advance
( ) Encode ( ) Study/Comment ( ) For Appropriate ____ Endorsement ____ Letter
Action ____ Answer to ____ Special Order
Correspondence Others:_______________
Remarks:

Schools Division Superintendent

Received by:
Office Name/Signature Date Action Taken

RECORDS CONTROL OF RETURNED DOCUMENTS

(To be filled out by the Record's Officer only)
Date Returned: Received by:

Date Released: Received by:

Signature over Printed Name of Requestee/ Representative

DOCUMENTS/REQUEST CLAIM FORM

No.
Date:
Name of Requestee:
Office/School:
Documents Requested:

Disclaimer: Unclaimed documents beyond 90 days upon receipt of the request will be discarded.