Republic of the Philippines

COMMISSION ON POPULATION AND DEVELOPMENT

Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 1: Checklist of Requirements for Application for Accreditation

 Certificate of Accreditation Application Form (See Annex B)

 Location Sketches and Photographs of the Principal Office and the Satellite
Offices (if applicable/available)
 Data Sheet of Directors, Trustees, Officers and Key Personnel (See Annex C)
 Organization chart (Indicate the names and designation of the members of your
organization)
 Articles of Incorporation/Cooperation as the case may be (Certified as true copy
of the original by the custodian of the document in the CSO)
 Omnibus Sworn Statement (See Annex F)
 Certificate of Registration Issued by the Securities and Exchange Commission,
Department of Labor and Employment, or Cooperative Development Authority
as the Case may be (Certified as true copy of the original by the issuing Agency or
the custodian of the document in the CSO)
 Audited Financial Statements for 2 years preceding the filing of the application
for accreditation (Certified as true copy of the original by the custodian of the
document in the CSO)
 List of on-going and past programs and projects (See Annex D)
 List of current areas of operation including staff complement (See Annex E)
 Financial documents of previous partnership with funding/donor agencies
establishing track record (if applicable)
 Other documents which CSO may submit to support its application for
accreditation, particularly as regards its capability and expertise on selected
geographical and/or technical areas of activity.
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 2: Certificate of Accreditation Application/Renewal Form

CERTIFICATE OF ACCREDITATION AS IMPLEMENTING ENTITY OF

POPCOM FUNDS APPLICATION/RENEWAL FORM

Date:
______________________

I. Identifying Information:

1. Name of CSO : __________________________________________________________________________

__________________________________________________________________________
2. Business : __________________________________________________________________________
Address __________________________________________________________________________
__________________________________________________________________________
3. CSO Head : __________________________________________________________________________
4. E-Mail : __________________________________________________________________________
5. Tel/CP/Fax __________________________________________________________________________
No.
6. Website (if : __________________________________________________________________________
any)
7. Registration and Permits (SEC, CDA, LGU, Other Licenses if any):
Permit No. Date and Place of Issuance
____________________________________ _______________________________________________________________
____________________________________ _______________________________________________________________
____________________________________ _______________________________________________________________
____________________________________ _______________________________________________________________
____________________________________ _______________________________________________________________

II. Objectives of the Civil Society Organization (Purpose state in the Articles of
Incorporation/Cooperation, and/or other purpose identified in CSOs Mission
Statements):
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
6. ________________________________________________________________________
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

III. Geographical Areas and Technical Areas of Activity

The [CSO] based on its previous and current operations, capacity, and expertise will
be applying for accreditation in the following geographical and technical areas of
activity (use additional sheets as may be necessary):

A. Geographical Area:1
Region Province
1. ___________ _______________________
2. ___________ _______________________
3. ___________ _______________________
4. ___________ _______________________
5. ___________ _______________________
6. ___________ _______________________
7. ___________ _______________________
8. ___________ _______________________
9. ___________ _______________________
10. ___________ _______________________
11. ___________ _______________________
12. ___________ _______________________
13. ___________ _______________________
14. ___________ _______________________
15. ___________ _______________________
16. ___________ _______________________
17. ___________ _______________________
18. ___________ _______________________
19. ___________ _______________________
20. ___________ _______________________
City/Municipality
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

B. Technical Area2:
1. __________________________________ 2. __________________________________
3. __________________________________ 4. __________________________________
5. __________________________________ 6. __________________________________
7. __________________________________ 8. __________________________________
9. __________________________________ 10. __________________________________

1
No need to fill out provincial, or city/municipality columns if application is region or province wide
respectively; just indicate “Region Wide” “Province Wide”
2
See List of Technical Areas of Activity for classification
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

IV. Budget:
1. Annual Budget (Latest): ________________________________________________
2. Source of Funds: (Please specify the CSO’s specific sources of funds whether
government or private organizations/individuals, local and/or
international/foreign including other resource generation activities with
corresponding amount of funds in peso value.)

a. Local Source Peso Value

__________________________________ ____________________
__________________________________ ____________________
__________________________________ ____________________
__________________________________ ____________________
__________________________________ ____________________

b. Foreign Source Peso Value

__________________________________ ____________________
__________________________________ ____________________
__________________________________ ____________________
__________________________________ ____________________

V. List of Attachments:

Accompanying this application form submitted are the following attachments

required under the Guidelines for Accreditation of Civil Society Organizations as
Implementing Entity of POPCOM Funds, and other supporting attachments which will
support the [CSO] application:
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
4. ______________________________________________________________________
5. ______________________________________________________________________
6. ______________________________________________________________________
7. ______________________________________________________________________
8. ______________________________________________________________________
9. ______________________________________________________________________

I hereby certify that the information on this application form is true and
complete.

_______________________________________________________________________
(Signature Over Printed Name of the CSO Head or Authorized Representative)
____________________________
(Date)
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 3: Sample Data Sheet for Directors, Trustees, Officers, and Key Personnel

Name:
Position:
ID Picture taken
not earlier than 6
Address:
months from
application E-mail:
CP No:
Phone
No.:
Existing Interest in other CSOs, Businesses, or other ventures:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Name:
Position:
ID Picture taken
not earlier than 6
Address:
months from
application E-mail:
CP No:
Phone
No.:
Existing Interest in other CSOs, Businesses, or other ventures:
1.
2.
3.
4.
5.
6.
7.
8.
9.
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 4: Sample List of On-Going and Past Programs and Projects

List of Current and Past Programs and Projects

Organization: ____________________________________________________

Project/Program Funding Agency Amount Remaining Project Duration Location Other Remarks
Title Received/ Unliquidated
Budget Fund
Training of DOH RO 10 P 1,000,000 500,000 January to June Region 10,
Community 2017 Cagayan de Oro
Volunteers on and Camiguin
IPCC Only
Conduct of RPFP POPCOM P 1,000,000 Fully liquidated June to December Region 4-A, Rizal,
Classes 2016 Province Wide
Printing of FP IEC Self Funded P 1,000,000 P 500,000 June to December Region 5, Legazpi
Materials 2017 City
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 5: Sample List of Current Areas of Operation Including Staff Complement

List of Current Areas of Operation Including Local Staff Available to Assist in Population Management Programs, Projects, and Activities

Organization: ____________________________________________________
Office Address3: ____________________________________________________

Summary of Areas of Operation and Staff Available:

Areas of Operation4 Number of Staff Available

Mandaluyong City, Metro Manila 10
Bobon, Northern Samar, Region VIII 10
Sulu, ARMM 20

List of Local Staff Available

Name Area of Operation Nature of Work5 Brief Description of Nature of Employment Services6
Relevant Experience or
Competency
Mr. K Mandaluyong City, Administrative Accountant Full-time
Manila
Ms. L Bobon, Northern Community Worker Former BSPO, Community Volunteer
Samar Organizer, IPCC Trained
Ms. M Sulu, ARMM Technical Staff Former Youth Leader, Peer Project Based
3
Note: If maintaining office at different localities, please indicate main office address followed by addresses of other offices maintained
4
Note: Particular City/Municipality should be indicated when staff committed is not available to operate in all of the Cities and Municipalities within the province
5
Refers to whether the staff identified is: Administrative Staff; Technical Staff; Community Worker
6
Refers to whether the staff identified is: Full-time Employee; Part-time Employee; Project Employee; Volunteer
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

Counselling Trainer
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 6: Omnibus Sworn Statement

REPUBLIC OF THE PHILIPPINES )

CITY/MUNICIPALITY OF _________ ) S.S.

AFFIDAVIT

I, [Name of Affiant who is the Chief Executive Officer or equivalent officer of the CSO],
[Nationality,] and residing at [Address of Affiant], after having been sworn in accordance with law, do
hereby depose and state that:

1. I am the [Chief Executive officer or Equivalent Officer of the CSO] with office address at [Official
address of the CSO];

2. As the [Position in the CSO] of [Official Name of the CSO as set forth under the Articles of
Incorporation/Cooperation as the case may be], I am granted full power and authority to do,
execute and perform any and all acts necessary and/or to represent the [CSO] in the
accreditation of process of POPCOM for CSOs as implementing entity of POPCOM Funds as
shown in the attached [state title of attached document showing proof of authorization, eg.
Board Resolution or duly notarized Secretary’s Certificate issued by the CSO];

3. The [CSO] is in good standing with all government agencies from which the CSO has received
public funds, and the CSO is not in default or in delay in liquidating nay public funds received
form any government agency;

4. Neither the [CSO] nor any of its past or present directors, trustees, officers, or key personnel is
a defendant, respondent, or accused in any civil, administrative, or criminal case arising from
or involving the use of public funds received by the [CSO]

5. Each of the documents submitted in satisfaction of the accreditation requirements is an

authentic copy of the original, complete, and all statements and information provided therein
are true and correct;

6. [CSO] is authorizing the POPCOM Accreditation Committee or its duly authorized agents as is
needed in the accreditation process, to verify all documents submitted and require additional
documents as the case maybe, conduct ocular inspection of the principal and satellite offices of
the CSO and/or the site of any past or present project or program of the applicant, and to
interview any or all of the directors, trustees, officers, or key personnel of the CSO, or any
person with past or present substantial dealings with the CSO;

7. That none of the Directors, Trustees, Officers or Key Personnel of the [CSO] is related within the
fourth civil degree of consanguinity or affinity to any POPCOM official involved in the
processing of its accreditation;

8. The [CSO] is aware of and has undertaken the following responsibilities as an applicant for
accreditation:
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

a. Carefully examine all documents submitted for accreditation

b. Carefully examine to be aware and to understand the Guidelines for Accreditation of
Civil Society Organizations as Implementing Entity of POPCOM Funds for the purpose of
strictly abiding with the same
c. Carefully ascertained and disclosed all information which are material to its
accreditation process though be not required by the Accreditation Committee

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ____, 20___ at
__________________________, Philippines.

___________________________________
Affiant’s Signature

[JURAT]

(SHALL BE NOTARIZED)
 Republic of the Philippines
COMMISSION ON POPULATION AND DEVELOPMENT
Acacia Lane Extension, Welfareville Compound, Barangay Addition Hills,
Mandaluyong City, Philippines 1550

FORM 7: List of Technical Areas of Activity

 Responsible Parenthood and Family Planning

o Data and Information Management
o Institutional Capacity Building
o Policy Formulation
o Plan Development
o Program Advocacy and Communication
o Demand Generation Activities
o Linking Unmet Need to Service Delivery
o Male Involvement in RPRH

 Adolescent Health and Development

o Data and Information Management
o Institutional Capacity Building
o Policy Formulation
o Plan Development
o Program Advocacy and Communication
o Repeat Pregnancy Prevention Program for Teens
o Establishment of Information and Service Delivery Network for AHD
o Teen Center Establishment

 Population and Development

o Data and Information Management
o Institutional Capacity Building
o Policy Formulation
o Plan Development
o Program Advocacy and Communication
o Conduct of PPMP-DP related researches

 Gender and Development

o Data and Information Management
o Institutional Capacity Building
o Policy Formulation
o Plan Development
o Program Advocacy and Communication
o Men’s Involvement in RPRH

 Special Population Groups (PWDS, Older Persons, Drug Surrenderees, Indigenous

Peoples)
o RPRH related activities for Special Population Groups
o Establishment/enhancement and utilization of demographic database and profiling
system for SPGs