Republic of the Philippines

Province of Surigao del Norte

BARANGAY ZARAGOZA
Surigao City
oOo

BARANGAY CLEARANCE
TO WHOM IT MAY CONCERN:

This clearance is hereby granted to:

Name of Applicant : ___________________________________________________________

Date of Birth : ___________________________________________________________

Place of Birth : ___________________________________________________________

Civil Status : ___________________________________________________________

Present Address : ___________________________________________________________

No. of Years Stay in Brgy. : ____________________________________________________________

PURPOSE : ____________________________________________________________

The above-name person is known to me be of good moral character and integrity, a law-abiding citizen in the
community, no derogatory record, no pending case filed in this office as of date as far as record is concern.

This clearance is being issued upon request of the above-mentioned person and for whatever legal purpose it
may serve him/her best.

Issued this___________ day of ____________________, 2019.

_________________________
Signature of Applicant

HON. DALE J. GEALOGO

Punong Barangay

CTC No.:__________________
Issued at:_________________
Issued on:_________________
OR No.:___________________