DA-CSO APPLICATION FORM

REPUBLIC OF THE
DEPARTMENT OF AGRICULTURE
PHILIPPINES

APPLICATION FORM FOR THE ACCREDITATION OF CIVIL SOCIETY ORGANIZATION/S (CSO)

AS BENEFICIARY OF GOVERNMENT OR PUBLIC FUNDS

Information on previous DA CSO Accreditation if applicable

Previous DA CSO
Accreditation No.
Date Issued
Date of Expiration

BASIC INFORMATION:

Complete name of CSO

(as stated/indicated on the registration papers)
Other Name
(e.g., acronym, short name, previous name, etc.)
No. and Street
Principal address or
Barangay
place where the Municipality
CSO operates as a Province
group Zipcode
Name
Head of CSO
Position/Designation
Landline No.
Mobile No.
Contact Details Email Address
Website
Name
Coordinator/Staff-in-
Position/Designation
Charge of Branch or
Satellite Office/s if
Contact Number
there is any
Purposes or reasons for organizing or forming
as a group
Government Agencies (Gas) from which the
CSO expects to receive public funds
Estimated amount of public funds to be
requested from the Gas

SOCIAL PREPARATION: (USE ADDITIONAL SHEET IF NECESSARY)

Social Issue/Problem Description of Geographical Location Beneficiary Sector/s:

Program/Project (pls. indicate specific (Fisher folks, Farmers, Persons with
Barangay,City/ Municipality, Disabilities, Children, Indigenous People,
Province and Region) Older Persons, Cooperative members,
mixed group, etc.)

DA-CSO APPLICATION FORM / BENEFICIARY CSO 1

AUTHORIZATION:

On behalf of the CSO Applicant, I hereby:

(a) Authorize the DA to inspect the premises of the office(s) of the CSO Applicant, as well as the
site of any past or present project or program of the CSO Applicant, and
(b) Authorize any concerned person to disclose the DA any fact material to the validation of any
information provided by the CSO Applicant in this application or in any of the documents
submitted in support thereof.

AFFIANT- Signature
Authorized Name
Representative Position/Designation
Date executed
Place executed

SUBSCRIBED AND SWORN to before me, on the above date and place, affiant exhibiting the
following identification document:
Government ID type and No.
Place and date of issue
Valid until

Doc. No. Signature

Name of Notary
Page No.
Public
Book No. Address
Commission valid
Series of
until

DA-CSO APPLICATION FORM 2

 BIO DATA PICTURE

Personal Information

Name
Position in the Board
Home Address
Date of Birth
Contact Number
Email Address
Nationality

Educational Attainment

Employment Record
1. Position
Employer
Dates
Duties

2. Position
Employer
Dates
Duties

CERTIFICATION

I, the undersigned, certify certify that these data are true and correct

Signature
Date
 ANNEX A1

OMNIBUS SWORN STATEMENT

Certification that:

 The CSO has authorized the application for accreditation and has authorized the person
actually filling the application to represent the CSO in the application.
 All supporting documents are authentic, true and correct.
 The CSO is not in default or delay in liquidating public funds received from any government
agency.
 Neither the CSO nor any of its member(s) has been blacklisted by any government agency.
 None of the members of the CSS has been convicted in any case, or is currently a defendant/
accused/ respondent in any pending case, related to the use of public funds.
 The CSO is aware of, understand, and agrees to abide by the guidelines for accreditation of
CSOs.

Declaration of:
 Other businesses of the CSO and its key personnel.

NOTARY PUBLIC
Doc No.
Page No.
Book No.
Series of 2021
 ANNEX A2

SECRETARY’S CERTIFICATE OF INCUMBENT OFFICERS

I, ______________________________, Secretary, of ________________________________ duly organized under the laws

of the Philippines do hereby certify that I maintain complete and accurate minute books on behalf of
the Corporation. I do further certify that any of those identified below, is authorized, in the name and
on behalf of the Corporation, to enter into, complete and execute agreements, and to give instructions
on behalf of the Corporation in writing or by telephone, facsimile transmission, telegram, teletype,
electronics means, or otherwise, with respect to all transactions, including but not limited to
instructions to pay, deliver or transfer property or cash of the Corporation to any third party
whatsoever.
I further certify that the following are officers of the Corporation elected or appointed until their
successors are elected or appointed and that you shall be entitled to rely upon their continued
incumbency and empowerment to act for the Corporation until you have been furnished with a duly
certified notice to the contrary.

NAME TITLE/ POSITION CONTACT NUMBER

IN WITNESS OF WHICH, I have hereunto set my hand as Secretary (or other duly authorized officer)
of the Corporation on this _____ day of _________, 2021 in ______________________.
_________________________________________
Signature
SUBSCRIBED AND SWORN TO before me this _______ day of ____________ 2021, affiant/s exhibit/s to me
(ID number) issued on __________________ issued at ______________________.

NOTARY PUBLIC
Doc No.
Page No.
Book No.
Series of 2021
 ANNEX A3

AFFIDAVIT OF DISCLOSURE OF OTHER RELATED BUSINESS

I/We, CSO director/trustee, of legal age, Filipino and with address

___________________________________________ after having been duly sworn in accordance with law, certify
that:

1. I/We am/are the (position) of the _____________________, a cooperative/corporation/association duly

organized and existing under and by virtue of laws of the Republic of the Philippines, with principal
office address at ___________________________________________________;

2. The Organization has no other related business and in the even that there will be other related
business, we shall immediately report it to the Department of Agriculture including any extent of
ownership therein;

3. That I am making this statement in compliance with Section 4.4.4. Commission on Audit (COA)
Circular No. 2007-001 dated October 25, 2007 and in accordance with the requirement of the
Department of Agriculture;

4. I understand and accept that any false statement in this respect will render the __________ and its
authorized officials liable for possession to the full extent of the law;

5. That this certificate is being made and executed for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________ day of _________ in
______________________.

SUBSCRIBED AND SWORN TO before me this _______ day of ____________ 2021, affiant/s exhibit/s to me
(ID number) issued on __________________ issued at ______________________.

NOTARY PUBLIC

Doc No.
Page No.
Book No.
Series of 2021
 ANNEX A4

SECRETARY’S CERTIFICATE

I, Secretary, of legal age, Filipino and with address ___________________________________________ after having
been duly sworn in accordance with law, certify that:

1. I am the Secretary of the _______________________________, a

corporation/organization/association/cooperative duly organized and existing under and by virtue
of laws of the Republic of the Philippines, with office address at
_____________________________________________________________________;

2. That none of its incorporators, organizers, directors of official in an agent of, or related by
consanguinity of affinity up to the fourth civil degree to the officials of the implementing agency who
are authorized to process accreditation and application;

3. That this certificate is being made and executed for whatever legal purpose it may serve

IN WITNESS WHEREOF, I have hereunto set my hand this ____________ day of _________ in
______________________. (

SUBSCRIBED AND SWORN TO before me this _______ day of ____________ 2020, affiant/s exhibit/s to me
(ID number) issued on __________________ issued at ______________________.

NOTARY PUBLIC

Doc No.
Page No.
Book No.
Series of 2021