REGION II TRAUMA AND MEDICAL CENTER

RSP Form No. 4 series of 2018

RELATIVE CHECKLIST FORM

__________________________
Date

Name of Applicant: _____________________________________________________________

Applied Position: _____________________________________________________________

This is to certify that I have a relative(s) in Region II Trauma and Medical Center (please
check and encircle relative)

Father / Mother / In-Laws (Biyenan) ______________________________

Brother / Sister / In-Laws (Bayaw/HIpag) __________________________

Husband / Wife _____________________________________________

Son / Daughter ______________________________________________

Uncle/Aunt (brother/sister of mother/father or brother-in-law/sister-in-law of mother/father)

______________________________________________________________

First Cousin _________________________________________________

This is to further certify that the above relative/s in the R2TMC are covered under the
following circumstances (Sec.6 of Rule XVIII of Omnibus Rules Implementing Book V of Executive
Order No. 292 and Other Pertinent Civil Service Laws):

Head of Agency/Appointing Authority

R e c o m m e n d i

Immediate Supervisor/Superior of the Office concerned

I declare under the penalties of perjury that the above answers are made in good faith and to
the best of my knowledge and belief are true and correct. I am willing to have my appointment
revoked if it is later found/discovered that I mis declared my relationship with the above-mentioned
relatives.

_____________________________
Signature of Applicant