Post on 16-Apr-2015
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REPUBLIC OF THE PHILIPPINESCIVIL SERVICE COMMISSION
QUEZON CITY
THIS FORM IS NOT FOR SALEREPRODUCTION IS ALLOWED
APPLICATION FORDISTANCE LEARNING PROGRAM APPLICATION NO:______________
DATE OF EXAM:________________NOTE:ACCEPTANCE OF APPLICATIONA FIRST COME FIRST SERVED BASIS
1. APPLICANT’S NAME (COMPLETE)
_____________________________________________________________________________________________________(SURNAME) (GIVEN NAME) (MIDDLE NAME)
_____________________________________________________________________________________________________2. MAILING ADDRESS (COMPLETE)
3. CIVIL STATUS _________________ 4. DATE OF BIRTH __________________ 5. SEX __________________
6. PLACE OF BIRTH _________________ 7. CITIZENSHIP: _______________ 8. TELEPHONE NUMBER ______________
9. EDUCATION (FILL IN APPROPRIATE COLUMN)
a. IF COLLEGE GRADUATE b. IF VOC’L. GRADUATE/UNDERGRADUATE
DEGREE FINISHED _____________________________MAJOR FIELD OF STUDY ________________________DATE GRADUATED _____________________________SCHOOL GRADUATED __________________________SCHOOL ADDRESS _____________________________
HIGHEST YEAR IN COLLEGE COMPLETED ______________COURSE ___________________________________________NO. OF UNITS EARNED ______________________________INCLUSIVE YEAR ATTENDED _________________________SCHOOL ATTENDED ________________________________SCHOOL ADDRESS _________________________________
10. GOVERNMENT SERVICE RECORDPOSITION STATUS OFFICE ADDRESS
11. CIVIL SERVICE/BOARD/BAR EXAMINATION PASSEDRATING DATE OF EXAMINATION PLACE OF EXAMINATION
12. HAVE YOU EVER BEEN DISMISSED FROM ANY EMPLOYMENT, FORCED TO RESIGN OR OTHERWISE DISCIPLINES AS A RESULT OF ADMINISTRATIVE CASE OR CONVICTED ON ANY VIOLATION OF LAW, ORDINANCE OR REGULATION BEFORE ANY ONE BEFORE ANY CIVIL COURT AND/OR MILITARY TRIBUNAL?
YES IF YES, ATTACH COPIES OF DECISIONSNO
I DECLARE UNDER T PENALTIES OF PERJURY THAT THE APPLICATION HAS BEEN ACCOMPLISHED IN GOOD FAITH, VERIFIED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND COMPLETE STATEMENT PURSUANT TO THE PROVISIONS OF THE PERTINENT LAWS, RULES AND REGULATIONS OF THE REPUBLIC OF THE PHILIPPINES.
__________________________________ SIGNATURE OF APPLICANT
13. DO NOT FILL THIS PORTION
ACTION TAKEN: APPROVED ____ DISAPPROVED ____ DATE ____________ SIGNATURE ___________________
OR NUMBER ________________DATE ______________________
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