REPUBLIC OF THE PHILIPPINES

CIVIL SERVICE COMMISSION

QUEZON CITY

Recent
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REPRODUCTION IS ALLOWED

APPLICATION FOR
DISTANCE LEARNING PROGRAM APPLICATION NO:______________
DATE OF EXAM:________________
NOTE:
ACCEPTANCE OF APPLICATION
A FIRST COME FIRST SERVED BASIS

1. APPLICANTS 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 VOCL.
GRADUATE/UNDERGRADUATE
DEGREE FINISHED HIGHEST YEAR IN COLLEGE COMPLETED
_____________________________ ______________
MAJOR FIELD OF STUDY COURSE
________________________ ___________________________________________
DATE GRADUATED NO. OF UNITS EARNED
_____________________________ ______________________________
SCHOOL GRADUATED INCLUSIVE YEAR ATTENDED
__________________________ _________________________
SCHOOL ADDRESS SCHOOL ATTENDED
_____________________________ ________________________________
SCHOOL ADDRESS
_________________________________

10. GOVERNMENT SERVICE RECORD

POSITION STATUS OFFICE ADDRESS

11. CIVIL SERVICE/BOARD/BAR EXAMINATION PASSED

RATING DATE OF PLACE OF
EXAMINATION 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 DECISIONS

NO

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 ______________________