1 Others 6
Country Code Area Code
2
Mobile:
3 E-mail:
7
□ Mobile □ E-mail 8
□ Mobile □ E-mail 4 Company/Affliation/Organization/School and Position: 9
5
10 11
12 13
□
14
15
16
URS-REC-F-03 Rev. 00 Effectivity Date: January 13, 2021
REFERENCE CODE:
For follow-ups or other inquiries, please contact (02)400-327 and look for the FOI Receiving Officer on duty FREEDOM OF INFORMATION REQUEST FORM
Republic of the Philippines UNIVERSITY OF RIZAL SYSTEM
Province of Rizal
Remarks:
Date: (DD/MM/YYYY) / /
For Official Use Only Received by:
Name/Signature:
Position:
Date and Time Received:
Any other relevant information:
I declare and certify that the information provided in this form is complete and correct. I am aware that giving false or misleading information or using forged documents is a criminal offense. I bind myself and my principal to use the requested information only for the specific purpose stated and subject to such other conditions as may be prescribed by the Office of the President. I understand that the Office of the President may collect, use and disclose personal information contained in this request.
Signature of Requesting Party or Representative:
Date of Document:(DD/MM/YYYY) / / Certified True Copy
Purpose of Request (Please be as specific as possible) PART II. REQUESTED INFORMATION
PART I. INFORMATION ON REQUESTING PARTY
Title of Document/Record Requested (Please provide as much detail as you can)
□ Photocopy □ Certified Photocopy
Apt/House No./Street Brgy/District City/Municipality
I.D. of Representative:
Proof of Authority:
First Name:
(Including M.I.)
□ Pick-up □ Postal Address
Name of Representative/Guardian: (If applicable) Surname
Number
( )( ) ( )( )
□ Postal ID □ Voter's ID Surname
Prepared Mode of Communication:
(For clarification and other matters)
□ Landline □ Postal Address
Prepared Mode of Reply/Response Contact Details:
Landline:
Fax:
Type of I.D. Given: (with photograph and signature)
□ Passport □ Driver's License □ Others (Pls. Specify) Province
First Name:
(Including M.I.) Complete Address:
Title: (Mr.MS.Mrs) Full Name:
