Examination Records Request Form (ERRF)

(July 2009) Date:

Time:
First Name Middle Name
Name Used at the Time of Exam (for Married Women):
Requested By:
Signature of the Signature at the Time of Exam
Examinee/Eligible
In Order Not In Order
School Code/Batch No. Examinee/Reg. No. Picture/Photo
Signature
NO AVAILABLE RECORD Date of Birth
Name/Signature/Initial of Verifiers and Validators:
1st Verifier: 2nd Verifier: 1st Validator: 2nd Validator:
Date: Date: Date: Date:
Released by Received by
Fee O.R. No.
Date: Printed Name & Signature of Cllient
Date of Exam/Issuance:
Contact No. Contact No.
Presently employed? (Yes or No ) If yes, specify Employer and Address:
Authorized Representative (Printed Name and Signature)
Rating Obtained:
Reg. No. for PD 1006/RA 1080/Other Special Laws:
Right Thumb Print
Title of Exam/Eligibility: Place of Exam/Issuance:
Registration Date:
(Failure to fill up this portion shall mean denial of the request)
Book No. Page No. Seq./Line No.
Date Released:
(Examinee/Eligible)
CHECKED DATA AGAINST THE PSP CHECKED DATA AGAINST THE ML
ACTION TAKEN
EXAMINATION/ELIGIBILITY DATA (Please print.)
CIVIL SERVICE COMMISSION
Republic of the Philippines
OFFICE NAME
Certification of Eligibility Authentication of Eligibility
Place of Birth:
Verification of
Eligibility
Civil Status:
Address Used at the Time of Exam:
Last Name
Purpose of Request:
Gender:
Date of Birth:
Current/Mailing Address:
REQUEST FOR EXAMINATION RECORDS
(for lost original certificate)
(attach original certificate)
Name of Examinee/Eligible:
PERSONAL INFORMATION (Please print. )
(Please see Guide and Requirements at the back page.)
RELEASE OF REQUEST/S
REMARKS
Action Officer
Attested by: ___________________
SECURITY FORM NO.




Not In Order
Date:_______
Time:_______
Contact No.
If yes, specify Employer and Address:
Authorized Representative (Printed Name and Signature)
Rating Obtained:
Place of Exam/Issuance:
Registration Date:
(Failure to fill up this portion shall mean denial of the request)
CHECKED DATA AGAINST THE PSP
Place of Birth:
Civil Status:
Purpose of Request:
Gender:
REQUEST FOR EXAMINATION RECORDS
Name of Examinee/Eligible:
Others:
(Please see Guide and Requirements at the back page.)
Attested by: ___________________
GUIDE IN ACCOMPLISHING THE EXAMINATION RECORDS REQUEST FORM (ERRF)
1. Do not leave any blank unanswered in accomplishing the request form.
2. Make sure that all information you provide are true and as written in your application for examination.
3. Right thumb print are clear and without smudges.
CHECKLIST OF REQUIREMENTS
A. CERTIFICATION OF ELIGIBILITY (for lost original certificate)
1. One piece "1 inch by 1 inch" picture with name tag and signature affixed prior to having the photograph taken
* Signature must be on top of the printed name.
* The photograph should have been taken within three (3) months prior to
filing of request for Certification of Eligibility.
* Scanned, computer-generated photo/name/signature will not be accepted.
2. Properly accomplished ERRF
3. Two (2) valid Identification Cards
4. Certification fee: Php100.00 per copy
5. If through a representative or if the requesting party is abroad, please refer to additional requirements below.
B. AUTHENTICATION OF ELIGIBILITY
1. Original Certificate of Eligibility or Report of Rating
2. Properly accomplished ERRF
3. One (1) valid Identification Card (if requesting party is the examinee/eligible)
Two (2) valid Identification Cards of the examinee/eligible (if request is filed through a representative)
4. Authentication fee: Php50.00 per copy
5. If through a representative or if the requesting party is abroad, please refer to additional requirements below.
Choices for Identification Card/s:
1. Company ID 4. Voter's ID 7. Driver's License 10. NBI Clearance
2. Taxpayer's ID 5. SSS ID 8. PRC License 11. Police Clearance
3. Passport 6. GSIS ID 9. NBT License
ADDITIONAL REQUIREMENTS
A. If request for certification or authentication is filed through a Representative:
1. Authorization Letter or Special Power of Attorney (SPA); and
2. One (1) valid Identification Card of the representative.
B. If the requesting party of the certification or authentication Works/Lives Abroad:
1. Copy of Passport; and } duly authenticated/validated by the Philippine Embassy or
2. Copy of one (1) Identification Card. } Consular Office
1. One piece "1 inch by 1 inch" picture with name tag and signature affixed prior to having the photograph taken
5. If through a representative or if the requesting party is abroad, please refer to additional requirements below.
5. If through a representative or if the requesting party is abroad, please refer to additional requirements below.
duly authenticated/validated by the Philippine Embassy or