Republic of the Philippines

Department of the Interior and Local Government

BUREAU OF FIRE PROTECTION
REGION XII

STATEMENT OF SERVICE RMS Form No. 01

(To be accomplished by Employer) RMS Form No. 01

NAME: ___________________________________________________________ (If married women, give full maiden name)

BIRTHDATE: _______________________________________ BIRTH PLACE:___________________________________

(Data herein should be checked from birth/baptism
COMPULSORY RETIRED:___________________________ certificate or some other reliable documents.)

This is to certify that the above-named employee have actually rendered services in this Office and other agency as
shown by the Service Records below, each line of which is supported by an appointment and other papers actually issued by
this Office and approved by the authorities concerned.

INCLUSIVE DATESRECORDS OF
APPOINTMENTOFFICE/ENTITYAUTHORITY(FROM-TO)POSITION/DESIGNATIONSTATUSSALARYSTATION/PLACE

Issued in compliance with Executive Order No. 54 dated August 10, 1954 and in accordance with Circular No. 58 dated
August 10, 1954 of the system.

Prepared and Verified by: Certified Correct from Records:

SFO1 Mikhael Francis N Falalimpa SFO4 Josiah A Delmo

Chief, Administrative Section Officer-in-Charge
BFP-QSF-PRMD-001 Rev. ØØ (03.08.21)
 Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGION XII

STATEMENT OF SERVICE RMS Form No. 01

(To be accomplished by Employer) RMS Form No. 01

NAME: ___________________________________________________________ (If married women, give full maiden name)

BIRTHDATE: _______________________________________ BIRTH PLACE:___________________________________

(Data herein should be checked from birth/baptism
COMPULSORY RETIRED:___________________________ certificate or some other reliable documents.)

This is to certify that the above-named employee have actually rendered services in this Office and other agency as
shown by the Service Records below, each line of which is supported by an appointment and other papers actually issued by
this Office and approved by the authorities concerned.

INCLUSIVE DATESRECORDS OF
APPOINTMENTOFFICE/ENTITYAUTHORITY(FROM-TO)POSITION/DESIGNATIONSTATUSSALARYSTATION/PLACE

Issued in compliance with Executive Order No. 54 dated August 10, 1954 and in accordance with Circular No. 58 dated
August 10, 1954 of the system.

Prepared and Verified by: Certified Correct from Records:

SFO1 Mikhael Francis N Falalimpa SFO4 Josiah A Delmo

Chief, Administrative Section Officer-in-Charge
BFP-QSF-PRMD-001 Rev. ØØ (03.08.21)