DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

BUREAU OF JAIL MANAGEMENT AND PENOLOGY

REGIONAL OFFICE III
Diosdado Macapagal Government Center, Maimpis, City of San Fernando, Pampanga
Tel no: 455-3901/ Eadd:riiibjmproprmhrd@gmail.com

SERVICE RECORD
(To be accomplished by Employer)

(If married woman, give also full maiden name)

NAME: Surname Name Middle Name
(Surname) (Name) Middle Name
BIRTH : 01 January 1990 (Data herein should be checked from birth or baptismal certificate or other
PLACE OF BIRTH: Place of birth reliable documents)

This is to certify that the employee named above actually rendered services in the office as shown by the service record below, each line of
which is supported by appointment and other papers actually issued by this office and approved by the authorities concerned.

SERVICE LEAVE of
(Inclusive Dates) RECORD OF APPOINTMENT OFFICE ENTITY/DIVISION Separation
Absence
From To Rank Designation Status Monthly w/o Pay Date
Station/Place Branch
Base Pay

********************************************************************************nothing follows**********************************************************************************************************

Issued in compliance with Executive Order No. 54, dated August 10, 1954 and in accordance with Circular No. 85, dated August 10, 1999
of the system.

Date Accomplished: January 01, 2021

Certified Correct:

Name
Rank
Designation
e)

cate or other

rd below, each line of

Separation
Cause

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ated August 10, 1999