Distance Learning Program Application Form (CSC Philippines)

REPUBLIC OF THE PHILIPPINES CIVIL SERVICE COMMISSION QUEZON CITY Recent photo

THIS FORM IS NOT FOR SALE REPRODUCTION IS ALLOWED APPLICATION FOR DISTANCE LEARNING PROGRAM

APPLICATION NO:______________ DATE OF EXAM:________________

NOTE: ACCEPTANCE OF APPLICATION A 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 _____________________________

10. GOVERNMENT SERVICE RECORD POSITION

HIGHEST YEAR IN COLLEGE COMPLETED ______________ COURSE ___________________________________________ NO. OF UNITS EARNED ______________________________ INCLUSIVE YEAR ATTENDED _________________________ SCHOOL ATTENDED ________________________________ SCHOOL ADDRESS _________________________________

STATUS

11. CIVIL SERVICE/BOARD/BAR EXAMINATION PASSED RATING DATE OF EXAMINATION

OFFICE ADDRESS

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 NO

IF YES, ATTACH COPIES OF DECISIONS

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 ____ ___________________ OR NUMBER ________________ DATE ______________________

DATE ____________

SIGNATURE