SERVICE RECORD
(To be accomplished by Employer)
Name:
Surname
Name
Middle Name
(If married woman, give also maiden name)
Birth:
Birth Date
Birth Place
(Data herein should be checked from birth or bap-
tismal certificate or some other reliable documents)
tismal certificate or some other reliable documents)
| BP NUMBER | |
| Remitting Agency BP# | |
| Present Station BP# | |
| PRESENT STATION |
This is to certify the employee named herein above actually rendered services in this 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.
| FROM (mm/dd/yyyy) |
TO (mm/dd/yyyy) |
DESIGNATION | STATUS | SALARY | STATION/PLACE OF ASSIGNMENT |
BRANCH | L/ABS. W/O PAY |
CAUSE | AGENCY CODE |
|---|
Authorized Leave of Absence w/o Pay:
Due to SL:
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.
Date Issued: 28-Aug-25
Valid unitl 6 months upon date of issue
Certified Correct:
For the Superintendent of City School;
MA. ROSE JOCELYN T. TALACAN
Administrative Officer V
