Republic of the Philippines

PROVINCE OF BUKIDNON
Municipality of Impasugong
Barangay POBLACION

Office of the Punong Barangay

CLEARANCE

Name: SUBLIRAN MICHELLE O.

(SURNAME) (FIRST) (M.I)

ALLAN B. CHIU Address: Purok 8, Poblacion, Impasugong, Bukidnon

Punong Barangay
Birth Place: Lantapan, Bukidnon
KAGAWAD: Date of Birth: July 5, 1985
Rudy D. Damayan Civil Status: Single
Neil James S. Acal CTC NO. 20612455
Jesusa C. Rivera Issued on: October 10, 2017
Rolando E. Eguia Issued At:
Abner L. Garcia
Diomedes D. Tulusan Signature: Right Thumb Mark
Florentino G. Mangga

IP Representative: TO WHOM IT MAY CONCERN;

DIONESIANO S. TOMLAY
Secretary: THIS IS TO CERTIFY that the above-named person whose
SHIRLEY A. CURIBA signature and right thumb mark appeared above has requested
clearance from this office.

Treasurer:
GINES M. GANTE THIS FURTHER CERTIFIES that he/she has no derogatory records
on file and that his /her character & moral reputation in the community
are known to be good.
BRK:
SEAN GENE PHILLIP T. AUZA
THIS CLEARANCE is issued upon request of the above-named
person for loan purposes.

ISSUED this 10th day of October 2017 at

Poblacion, Impasugong, Bukidnon.

KAG. JESUSA C. RIVERA

For the Puno Officer-in-charge
Not Valid Without Official Seal Name & Designation of Issuing Officer

OR Number: 6577350 SHIRLEY A. CURIBA

Issued on: October 10, 2017 Barangay Secretary
Place of Issue Poblacion, Impasugong, Bukidnon Name & Designation of Issuing Officer
 Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______

PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANC

NAME : ________________________________________ NAME : ____________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: ______________________________________ BIRTHPLACE: ______________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________

TOTAL TOTAL

DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:

1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION

2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________

PUROK/SITIO LEADER PUROK/SITIO LEADE

Municipality of Impasugong Municipality of Impasugong

Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______

PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANC

NAME : ________________________________________ NAME : ____________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: _______________________________________ BIRTHPLACE: ______________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
b.___________________________ b.___________________________
 TOTAL TOTAL

DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:

1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION

2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________

PUROK/SITIO LEADER PUROK/SITIO LEADE

gong
ON
__

ARANCE
_____________

________________

FINE

MBLY

______
_____

OTAL

________

TIO LEADER

gong
ON
__

ARANCE
_____________

_______________

FINE

MBLY

______
_____
OTAL

________

TIO LEADER
 Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______

PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE

NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: ______________________________________ BIRTHPLACE: ______________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________

FINE FINE

1. ATTENDED PAHINA 1. ATTENDED PAHINA

2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY

3. PAID MONTHLY DUES 3. PAID MONTHLY DUES

4. OTHERS 4. OTHERS

a. ___________________________ a. ___________________________

b.___________________________ b.___________________________

TOTAL TOTAL

DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:

1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION

2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________

PUROK/SITIO LEADER PUROK/SITIO LEADER

Municipality of Impasugong Municipality of Impasugong

Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______

PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE

NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: _______________________________________ BIRTHPLACE: _____________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
 b.___________________________ b.___________________________

TOTAL TOTAL

DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:

1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION

2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________

PUROK/SITIO LEADER PUROK/SITIO LEADER

___

_______

___

______
 Municipality of Impasugong Municipality of Impasugong
Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______

PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE

NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: ______________________________________ BIRTHPLACE: ______________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________

FINE FINE

1. ATTENDED PAHINA 1. ATTENDED PAHINA

2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY

3. PAID MONTHLY DUES 3. PAID MONTHLY DUES

4. OTHERS 4. OTHERS

a. ___________________________ a. ___________________________

b.___________________________ b.___________________________

TOTAL TOTAL

DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:

1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION

2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________

PUROK/SITIO LEADER PUROK/SITIO LEADER

Municipality of Impasugong Municipality of Impasugong

Barangay POBLACION Barangay POBLACION
PUROK/SITIO ______ PUROK/SITIO ______

PUROK/SITIO CLEARANCE PUROK/SITIO CLEARANCE

NAME : ________________________________________ NAME : ________________________________________
BIRTHDAY: ___________________________ BIRTHDAY: ___________________________
BIRTHPLACE: _______________________________________ BIRTHPLACE: _____________________________________
CIVIL STATUS: _______________ CIVIL STATUS: _______________
FINE FINE
1. ATTENDED PAHINA 1. ATTENDED PAHINA
2. ATTENDED PUROK/SITIO ASSEMBLY 2. ATTENDED PUROK/SITIO ASSEMBLY
3. PAID MONTHLY DUES 3. PAID MONTHLY DUES
4. OTHERS 4. OTHERS
a. ___________________________ a. ___________________________
 b.___________________________ b.___________________________

TOTAL TOTAL

DOCUMENTS REQUESTED: DOCUMENTS REQUESTED:

1. BARANGAY CERTIFICATION 1. BARANGAY CERTIFICATION

2. BARANGAY CLEARANCE 2. BARANGAY CLEARANCE
3. BUSINESS CLEARANCE 3. BUSINESS CLEARANCE
4. OTHERS 4. OTHERS
Please specify ______________________ Please specify ______________________

PUROK/SITIO LEADER PUROK/SITIO LEADER

___

_______

___

______