OMNIBUS SWORN STATEMENT

REPUBLIC OF THE PHILIPPINES

MAMBUSAO, CAPIZ

I QUEENIE V. CUSAY, of legal age, single, and resident of Barangay Milan, Jamindan, Capiz
after having been duly sworn in accordance with law, do hereby depose and say:

1. I am the owner of the following documents submitted to the School Screening Committee:

a. CSC Form 212 (Personal Data Sheet) with latest 2x2 Id pictures;
b. PRC Professional Identification Card (not expired) or claim slip of
application/renewal;
c. Result of Rating obtained in Licensure Examination For Teachers (LET)/ Professional
Board Examination for Teachers (PBET)
d. Transcript of Records (TOR) with Certification General Weighted Average of Academic
grades;
e. Certificates of Specialized Training;
f. Voter’s ID and/ or Barangay Certification of Residency as deemed acceptable by the
School Screening Committee; and
g. NBI Clearance (not expired)

2. Each of the documents summited is in satisfaction and compliance with the requirements
for the recruitment set by the Department of Education

3. Each document is an authentic copy of the original ,complete, and all data/ validate
the documents submitted; and

4. I assure responsibility and accountability on the validity and authenticity of the

documents summited; and

5. I am authorizing the School Division Screening Committee to verify/validate the

documents summited.

IN WITNESS WHEREOF,I have set my hand this 28th day of January 2019 in Mambusao, Capiz,
Philippines.

QUEENIE V. CUSAY

Signature of Applicant

SUBSCRIBE AND SWORN TO before me this 28th day of January 2019, affiant exhibiting to me
his Community Tax No.08237688 issued on January 28, 2019 in Jamindan, Capiz, Philippines.

Doc. No._____
Page No._____
Book No._____
Series of _____
OMNIBUS SWORN STATEMENT
REPUBLIC OF THE PHILIPPINES
MAMBUSAO, CAPIZ

I BEVERLY C. PANUNCIO, of legal age, single, and resident of Barangay Milan, Jamindan,
Capiz after having been duly sworn in accordance with law, do hereby depose and say:

6. I am the owner of the following documents submitted to the School Screening Committee:

h. CSC Form 212 (Personal Data Sheet) with latest 2x2 Id pictures;
i. PRC Professional Identification Card (not expired) or claim slip of
application/renewal;
j. Result of Rating obtained in Licensure Examination For Teachers (LET)/ Professional
Board Examination for Teachers (PBET)
k. Transcript of Records (TOR) with Certification General Weighted Average of Academic
grades;
l. Certificates of Specialized Training;
m. Voter’s ID and/ or Barangay Certification of Residency as deemed acceptable by the
School Screening Committee; and
n. NBI Clearance (not expired)

7. Each of the documents summited is in satisfaction and compliance with the requirements
for the recruitment set by the Department of Education

8. Each document is an authentic copy of the original ,complete, and all data/ validate
the documents submitted; and

9. I assure responsibility and accountability on the validity and authenticity of the

documents summited; and

10. I am authorizing the School Division Screening Committee to verify/validate the

documents summited.

IN WITNESS WHEREOF, I have set my hand this 28th day of January 2019 in Mambusao, Capiz,
Philippines.

BEVERLY C PANUNCIO

Signature of Applicant

SUBSCRIBE AND SWORN TO before me this 28th day of January 2019, affiant exhibiting to me
his Community Tax No. 22336390 issued on January 28, 2019 in Jamindan, Capiz,
Philippines.

Doc. No._____
Page No._____
Book No._____
Series of _____