Office of the Senior Citizen Affairs

Office of the Senior Citizen Affairs

Municipality of New Lucena

Date Applied_________________Name_________________________________________________________________________

Surname

First Name

Middle name

Date of Birth___________________Age___________Sex__________CS__________________

Place of Birth__________________________________________________________________

Address_______________________________________________________________________

Educ. Attainment_______________________________________________________________

Occupation_________________________________Annual Income_______________________

Other Skills____________________________________________________________________

Family Composition

NameAgeCSRelationshipOccupation

Use other side of this form if necessary

Name of Association joined_______________________________________________________

Address of the Association________________________________________________________

Date of Membership_____________________________________________________________

If an officer, date elected_________________________________________________________

I certify that the above information is true and correct to the best of my knowledge and belief.Note: This registration form shall be secured at the senior citizen OSCA and prepare 1- 1x1 picture for OSCA ID.

________________________

Signature of Applicant

Res. Cert. No.____________

Date Issued______________

Place Issued_____________Requirements:

A. Submit one of the following:

1. Baptismal Certificate

2. Birth Certificate

3. Voters Affidavit

4. Joint Affidavit and Certifications5. Marriage Contract

6. Certification of Age and Date of Birth by the Punong Barangay

7. Any ID that shows, date of birth and age

B. Certificate of Waste Segregation duly signed by BEW and noted by the Punong Barangay

C. Membership fee of Php 30.00