DSWD-HRMDS-GF-015 | REV 00 /28 DEC 2021

DOCUMENT REQUEST FORM

_______________________
Date

The Personnel Administration Unit Head

Human Resource Management and Development Division
DSWD – Field Office X

May I request for issuance of:

Service Record
Certificate of Employment
Certificate of Leave without Pay
Certificate of Leave Credits
Duly Accomplished Office Clearance Certificate Form
Others (please specify): ___________________________________________________________

Purpose: _____________________________________________________________________________
_____________________________________________________________________________________

Additional Information (if requested):

Salary/Cost of Service
Service/Contract Gaps (if any)
Others (please specify): _______________________

_______________________________ ________________________
Office Signature over Printed Name

Contact no.: _____________________

==================================================================================
PLEASE FILL-OUT COMPLETELY FOR VALIDATION PURPOSES.
NAME:____________________________________________________________________________________
(FAMILY NAME) (FIRST NAME) (MIDDLENAME)

DATE OF BIRTH: _________________________PLACE OF BIRTH:___________________________________

EMAIL ADDRESS: __________________________________

PREFERRED MODE FOR RELEASING: WALK-IN / PERSONAL E-MAIL SERVICE COURIER

Note: If in case the requesting party is unable to claim his/her documents personally, authorized
representative must submit an authorization letter bearing their signatures with a photocopy of
the ID of the representative

HRMDD-PERSONNEL-A-RQST-22-05-0016-S