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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