DSWD-RLA Form 2

Republic of the Philippines

Department of Social Welfare and Development

APPLICATION FOR REGISTRATION AND LICENSING OF

SOCIAL WELFARE AND DEVELOPMENT AGENCIES

Date: _______________________

Type of Application : Status of Application: Scope/Coverage:

(Please check the appropriate box)

Registration
New Application
More than one Region/

People’s Organization
Renewal Nationwide

Resource Agency DSWD Previously Issued
Regional

SWD Network Certificate No: ____________

Registration and Licensing Date of Issuance: ___________ Service Delivery Mode

Residential-based Agency Date of Expiration: ___________
Residential-Based

Community-based Agency
Community Based

Child Placing Agency

Resource Agency providing direct services

I. Identifying Information:
1. Name of Agency: 2. Business Address:
_________________________________ ______________________________________
(No., Street/Subdivision, Barangay)
_________________________________
______________________________________
_________________________________ (Municipality/City)
3. Agency Head ______________________________________
(Province)
_________________________________
4. Position Title/Designation: 5. Telephone/Mobile/Fax Nu1mbers
_________________________________ _____________________________________
6. E-mail Address: 7. Website:
_________________________________ _____________________________________
7. Registration/Permit No: 8. Date of Issuance of Registration/Permit
71. SEC No: ___________________ 8.1 SEC Issued: ________________________
7.2. CDA No. ____________________ 8.2. CDA Issued: ________________________
7.3. Mayor’s Permit No. ____________ 8.3. Mayor’s Permit Issued: ________________

Reminder: Any private SWDA that intends to engage or is currently engaged in social welfare and development activities
shall apply for registration or registration and license to operate with the concerned DSWD Office within six (6) months after
its registration with the SEC or with CDA that gives juridical personality to an agency to operate in the Philippines.

(Please use additional sheet/s, if necessary)

II. Specific Objectives of the Agency (pls. state):

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

5. ____________________________________________________________________________

6. ____________________________________________________________________________

III. Program Profile (Please indicate all the programs and services for implementation/operation and/or
being implemented/operated by the applying SWDA):
Area of
Target Clientele
Type of Coverage/Location (Please check the appropriate column)
Programs and (pls. specify)
Services per

Disasters
Children
Province

Commu-

(Specify)
Munici-

Women

Victims
Region

Family
Person

Others
Youth

Older
pality

PWD
City/

Service Delivery

nity
Mode

1. Direct Program/s (pls. specify all the programs and services that is directly provided to the clientele per area of operation)
a. Community-based

b. Residential-based (pls. indicate specific name of each facility and services provided to the clientele)
 Area of
Target Clientele
Type of Coverage/Location (Please check the appropriate column)
Programs and (pls. specify)
Services per

Disasters
Children
Province

Commu-

(Specify)
Munici-

Women

Victims
Region

Family
Person

Others
Youth

Older
pality

PWD
City/
Service Delivery

nity
Mode

2.Indirect Program/s (Please specify all those are supportive activities in the delivery of social
welfare and development programs and services to the disadvantaged sector/s).
a. Funding

b. Training/Capability Building

c. Technical Assistance

d. Research

e. Advocacy/IEC Development

d. Others

IV. Personnel (current year)

No and Composition Technical Staff Administrative Staff Registered Community
of Staff Complement Social Worker Development Worker

Full time/
Regular Staff

Part time Staff

Volunteer Staff
V. Budget:

1. Annual Budget (Latest):_______________________________________________________

2. Source of Funds: (Please specify the SWDA’s specific sources of funds whether government or
private organizations/individuals, local and/or international/foreign including other resource
generation activities with the corresponding amount of funds in peso value.)

a. Local Source Peso Value

_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________

b. Foreign Source Peso Value

_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________
_________________________________ _____________________

I hereby certify that the information on this application form is true and complete.

________________________________________________________________________
(Signature Over Printed Name of the Agency Head or Authorized Representative)

______________________________________________________
(Position/Designation of the Agency Head or Authorized Representative)

________________________________
(Date)