Republic of the Philippines

BARANGAY MAPULANG LUPA

Valenzuela City
OFFICE OF THE PUNONG BARANGAY
APPLICATION FORM (BARANGAY CLEARANCE-INDIVIDUAL)
Clearance No.______
Please Check:
New Renewal Clearance No.: _____________
Date Issued: _____________ Date: _______________

Name: ____________________________________________________________________________________ Sex: _____________

Surname Given Name Middle Name

Present Address: _________________________________________________________________,_Mapulang Lupa, Valenzuela.City

Provincial Address: __________________________________________ Organization /HomeOwners:_________________________
Date of Birth: ______________ Age: ______Place of Birth:________________________ Contact #: __________________________
Civil Status:___________________ Residence Since:______________________ Precint No.: ______________________________
Occupation: _________________________ If employed, Name of company: _____________________________________________
Purpose of Clearance: _________________________________________________________________________________________
Reference(At least two NOT YOUR RELATIVE): 1.)___________________________ 2.) _____________________________________

CTC No. : _______________

Issued On.:_______________ _____________________________
Issued at: ________________ Applicant Signature

Fee :_______________
O.R. No. :_______________
Issued at :_______________
_________________________ Remarks: ____________________
Reference/ Neighbor’s Signature ____________________________
Over printed Name

Republic of the Philippines

BARANGAY MAPULANG LUPA
Valenzuela City
OFFICE OF THE PUNONG BARANGAY
APPLICATION FORM (BARANGAY CLEARANCE-INDIVIDUAL)
Clearance No._______
Please Check:
New Renewal Clearance No.: ___________
Date Issued: ____________ Date: _______________

Name: ____________________________________________________________________________________ Sex: _____________

Surname Given Name Middle Name

Present Address: ___________________________________________________________________Mapulang Lupa, Valenzuela.City

Provincial Address: _____________________________________________ Organization /HomeOwners:______________________
Date of Birth: _______________ Age: _____ Place of Birth:________________________ Contact #: __________________________
Civil Status:___________________ Residence Since:_________________ Precint No.: ______________________________
Occupation: _________________________ If employed, Name of company: _____________________________________________
Purpose of Clearance: _________________________________________________________________________________________
Reference(At least two NOT YOUR RELATIVE): 1.)___________________________ 2.) _____________________________________

CTC No. : _______________

Issued On.:_______________ _____________________________
Issued at: ________________ Applicant Signature

Fee :_______________
O.R. No. :_______________
Issued at :_______________

___________________________ Remarks: ____________________

Reference/ Neighbor’s Signature ____________________________
Over printed Name
 Republic of the Philippines
BARANGAY MAPULANG LUPA
Valenzuela City
OFFICE OF THE PUNONG BARANGAY
APPLICATION FORM
CERTIFICATION/ CERTIFICATE OF INDIGENCY/SOLICITATION AND OTHER

____________________
Petsa

Pangalan: _______________________________________________________________________________________________________
Apelyido Pangalan Gitnang Pangalan

Kasalukuyang tirahan: _____________________________________________________________________________________________

Tirahan sa Probinsya: ___________________________________________________ Samahan/HomeOwners:______________________
Kapanganakan: __________________________ Edad: _______________ Lugar ng Kapnganakan: _______________________________
Pangalan ng Asawa kung meron: _____________________________________ Edad: __________________________________________
Kailan ka natira sa Mapulang Lupa: _______________ Botante? OO_____ Precint No. ________________ Hindi ?___________________
Sa inyo ba ang bahay? OO ________, Hindi_________, Umuupa _________ May-ari ng Paupahan: _______________________________
Hanap-buhay: ______________________________ Pangalan ng kumpanya: _________________________________________________
Kakilala sa tinitirhan (kilala mo at kilala ka)

1.)________________________________________________
2.)__________________________________________________

Ano ang kailangan ssa barangay? ____________________________________________________________________________________

____________________________________________________________________________________
Sino ang inihingian ng tulong? _____________________________________________________________ Edad: ____________________
Saang Ahensya o kanino ilalapit?
_____________________________________________________________________________________

Sedula (No.) :_____________________ Kaukulang Bayarin: __________________

Kalian kinuha:_____________________ O.R No. : __________________________ _______________________
Saan kinuha: _____________________ Petsa: __________________________ Lagda ng Impormante

Remarks:_________________________ Inaprubahan ni:

_________________________________ _______________________
_________________________________ Opisyal ng barangay

Republic of the Philippines

BARANGAY MAPULANG LUPA
Valenzuela City
OFFICE OF THE PUNONG BARANGAY
APPLICATION FORM
CERTIFICATION/ CERTIFICATE OF INDIGENCY/SOLICITATION AND OTHER

____________________
Petsa

Pangalan: _______________________________________________________________________________________________________
Apelyido Pangalan Gitnang Pangalan

Kasalukuyang tirahan: _____________________________________________________________________________________________

Tirahan sa Probinsya: ___________________________________________________ Samahan/HomeOwners:______________________
Kapanganakan: __________________________ Edad: _______________ Lugar ng Kapnganakan: _______________________________
Pangalan ng Asawa kung meron: _____________________________________ Edad: __________________________________________
Kailan ka natira sa Mapulang Lupa: _______________ Botante? OO_____ Precint No. ________________ Hindi ?___________________
Sa inyo ba ang bahay? OO ________, Hindi_________, Umuupa _________ May-ari ng Paupahan: _______________________________
Hanap-buhay: ______________________________ Pangalan ng kumpanya: _________________________________________________
Kakilala sa tinitirhan (kilala mo at kilala ka)

1.)________________________________________________
2.)__________________________________________________

Ano ang kailangan ssa barangay? ____________________________________________________________________________________

____________________________________________________________________________________
Sino ang inihingian ng tulong? _____________________________________________________________ Edad: ____________________
Saang Ahensya o kanino ilalapit?
_____________________________________________________________________________________

Sedula (No.) :_____________________ Kaukulang Bayarin: __________________

Kalian kinuha:_____________________ O.R No. : __________________________ _______________________
Saan kinuha: _____________________ Petsa: __________________________ Lagda ng Impormante

Remarks:_________________________ Inaprubahan ni:

_________________________________ _______________________
_________________________________ Opisyal ng barangay