City of San Fernando, (P)

City Mayor’s Office

Community Affairs Division
Office of the Senior Citizens Affairs
Control No. _________
Date: ______________

APPLICATION FORM
NAME: ___________________________ __________________________ ___________________
(Last Name) (First Name) (Middle Name)

Present Address: ___________________________________________, City of San Fernando, Pampanga

(Street/Purok/Zone/Subd.) (Barangay) (City/Municipality) (Province)

Previous Address: ______________________________________________________________________

(Street/Purok/Zone/Subd.) (Barangay) (City/Municipality) (Province)

Place of Birth: ___________________________________________ ___________________________

(City/ Municipality) (Province)

Date of Bith: __________________________ ____________________ ___________________

(Month/Day/Year) (Gender) (Civil Status)

In case of emergency, please notify: NAME: _________________________________________________

Address: ____________________________________________ Relationship: ______________________
Contact No.: ____________________________

___________________________________ REQUIREMENTS:
Signature Over Printed Name of Applicant 1. Birth Certificate (LCR/NSO/PSA)
2. Brgy. Clearance
3. 1x1 Picture
4. Any of the following: (Pls. Photo Copy)

Passport, Voter’s ID, Driver’s License,

PRC and Government Issued ID’s)

Left Thumb Mark Right Thumb Mark

ass CAD-OSCA Control No.:____________

Barangay _______________________________
City of San Fernando, Pampanga

To Whom It May Concern:

This is to certify that _____________________________________________ is a bonifide resident of

__________________________________________________, City of San Fernando, Pampanga and is
now a member of the Senior Citizens of this barangay.

This certification is being issued upon request of abovementioned person for whatever legal intent and
purpose it may serve.

Given this _____________________________________ at barangay ____________________________,

City of San Fernando, Pampanga.

___________________________ Noted by:

Signature Over Printed Name
Senior Citizens President

_________________________
Signature Over Printed Name
Barangay Captain