Name of School

Address
Tel No.

SERVICE RECORD
(To be accomplished by Employer)

NAME: LAST NAME, FIRST NAME MIDDLE NAME (If married woman, give all full maiden
(Last Name) (Given Name) (Middle Name) name)
BIRTH: August 15, 1985 Gapan City, Nueva Ecija (Data herein should be checked from the
(Date) (Place) birth or baptismal certificate or some
other reliable documents.)

This is to certify that the employee named hereinabove actually rendered

services in this office as shown by the record below, each line of which is
supported by appointment and the other papers actually issued by this Office and
approved by the authorities concerned.

SERVICE L/V SEPARATION

RECORD OF APPOINTMENT OFFICE ENTITY/DIV.
(Inclusive Dates) ABS 4
Status Salary Station/Place of Branch W/O
From To Designation PAY Date
1 2 assignment 3

June March Classroom Prob. 9,000.00 Private March 19,

2009 2010 Teacher Montessori School - 2010
Gapan City

x-x-x-x-x-x NOTHING FOLLOWS -x-x-x-x-x-x

 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.
CERTIFIED CORRECT:
Yolanda V. Espinosa
Chief or Head Office
April15,2009 Registrar
Date Designation
 full maiden

cked from the

te or some

PARATION
4

Cause

Resigned
pinosa
Office
r
n