Pnp Id Application Form CS FORM No 100 C Revised 2007 Republic of by yxd16968

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									CS FORM No. 100-C (Revised 2007)                                                                                                          Republic of the Philippines
THIS FORM IS NOT FOR SALE                                                                                                               CIVIL SERVICE COMMISSION
REPRODUCTION IS ALLOWED                                                                                                                 Region: _________________                                        APPLICATION NO. ________

    NOTE: THOSE WHO HAVE ALREADY TAKEN AND FAILED BOTH THE JULY 17, 2005 CSEE/MATB AND THE JUNE 25, 2006 CEOE
                               WILL ONLY BE QUALIFIED TO TAKE THE CEOE IN 2009.
           CAREER EXECUTIVE OFFICER EXAMINATION (CEOE)                                                                                                                     DATE OF EXAM:                 06    10       07
                TITLE OF EXAMINATION APPLIED FOR                                                                                                                                        ( mm /    dd /    yyyy )
                         [READ THE EXAMINATION ANNOUNCEMENT. DO NOT APPLY IF YOU
                                            ARE NOT QUALIFIED]                                                                                                         PLACE OF EXAM:
1. APPLICANT'S NAME (PRINT IN CAPITAL LETTERS)
__________________ __________________________ _____ ______________________ _______ 2. AGE: ____________
                           (LAST NAME)                                                                     (FIRST NAME)       Name Extension,e.g. Jr., Sr., III)   (MIDDLE NAME)                    (M.I.)
3. APPLICANT'S MAIDEN NAME: _________________________ __________________________ ____________________
                                (For Married Women)                                                                     (FIRST NAME)                                        (MIDDLE NAME)                                  (LAST NAME)

4. COMPLETE MAILING ADDRESS                           Zip Code                  Tel. No.: _______________
                                                                                Cell.
____________________________________________________________________________________No.: ______________
                       6. SEX:Male Female
5. CIVIL STATUS: _______________            7.HEIGHT(m.) _____8.WEIGHT(kg)_____ Email add:_______________
9. BIRTHDATE:                                                                                                           10. BIRTHPLACE : ______________________ 11. CITIZENSHIP: ____________
                                                                                            ( yyyy    mm      dd)                                                  (City / Town / Province)
12. HIGHEST EDUCATIONAL ATTAINMENT:
              Level of                                                                         Course/Degree              Highest Grade/Year/              Name of School Attended                   Inclusive Years          Academic
             Education                                                                          (Write in full)            Level/Units Earned                and School Address                       Of Attendance        Honors Received
                                                                                                                          (Or Write Graduated)                                                     FROM         TO


13. PRESENT EMPLOYMENT                                                                                                       o      Government                         o     Private
                                                                                                                            POSITION LEVEL/                                                       LENGTH OF                STATUS OF
                                                    AGENCY/OFFICE/ADDRESS                                                   SALARY GRADE                           POSITION                     EXPERIENCE IN             APPOINTMENT/
                                                                                                                           RANK(for PNP/AFP)                                                  PRESENT POSITION            EMPLOYMENT



14. CIVIL SERVICE/BOARD/BAR/EXAMINATIONS PASSED (Use separate sheet if necessary)
                                                                                                                                                              Rating                Date of Exam                     Place of Examination




15. Have you ever been dismissed from the service for cause, or found guilty of crime involving moral turpitude, or of infamous, disgraceful
    or immoral conduct, drunkenness or addiction to drugs, or of offense relative to or in connection with the conduct of a civil service
    examination?    YES [ ]      NO [ ]        If YES , attach copy/ies of decisions.
16. Have you passed the same examination?        YES [ ]        NO [ ]
       I declare under oath that this application has been accomplished by me 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 pertinent laws, rules and
regulations of the Republic of the Philippines.
      I likewise agree that I will subject myself to a validating examination in case the test results in my place of examination
are statistically improbable.
                                           Printed Name and Signature of Collecting




                                                                                                                                                                                                                      Recently taken
         ____________________________
             ________________________
           __________________________
____________________________________




                                                                                                                      _______________________                                                                      Passport Size Photo
                                                                                                                           Signature of Applicant                                                                     w/ Name Tag
                                                                                                                                                                                                                       (Full Name)
                                                                                                                                                                            Right Thumbmark                             [1 1/2" x 2"]
                                                                                                                                                                                                                   (taken within 3 mos)
                                                                                       Subscribed and sworn to before me this ________ day of __________________ 2007.                                              Scanned/Digitally-
                                                                                                                                                                                                                   Imaged/Photocopied
                                                                                                       ADMINISTERING OFFICER                                               OFFICE/POSITION                         picture not accepted
                                                                                                       (Signature above Printed Name)
       No.
Amount:




                                                                                      ( Do not fill-up this portion. For Processor/s only )
                                           Officer
Date:




                                                                                      ACTION TAKEN: APPROVED [ ]              DISAPPROVED [ ]                      DATE _____________            _________________________________
O.R.




                                                                                                                                                                                                 Printed Name and Signature of Processor
                                           Printed Name and Signature of Collecting
            ____________________________
                ________________________
              __________________________




                                                                                            APPLICATION RECEIPT                       Application No. ____________                                                    Recently taken
______________________________________




                                                                                      Received the application for the: CAREER EXECUTIVE OFFICER EXAMINATION                                                       Passport Size Photo
                                                                                                                                                                                                                      w/ Name Tag
                                                                                      TIME: ___________________ Printed Name of Processor: _________________________
                                                                                             7:00 am                                                                                                                   (Full Name)
                                                                                      DATE: _____________________ Signature of Processor: _____________________
                                                                                             JUNE 10, 2007                                                                                                              [1 1/2" x 2"]
                                                                                      PLACE: ___________________________ Date Received/Processed: ________________                                                 (taken within 3 mos)

                                                                                              Applicant's Printed Name: _____________________________________________________                                        Scanned/Digitally-
                                                                                              Birthdate: _____________________________________ Sex: _________________________                                      Imaged/Photocopied
                                                                                              Signature: _______________________________________________________________________                                   picture not accepted
        No.




                                                                                           WARNING: Impersonation, cheating and other forms of examination irregularity would lead to
Amount:


                                           Officer




                                                                                                    dismissal from government service, perpetual disqualification from taking civil
Date:
O.R.




                                                                                                    service examinations and from entering government service and/or imprisonment.
                                                                                                      - Please Page for Page Important Examination Information -
                                                                                            - Please see Back see Back Other for Other Important Examination Information -
DECLARATION:
1. How many subordinates/staff do you supervise?
                    none        1       2       3       4       5       more than 5


2. Reasons for taking the CEOE: _______________________________________________________________________
3. Have you attended review classes in preparation for the examination? _________________________________________
   If YES , what Review Center? __________________________________________________________________________

      I declare that the abovementioned information are true and correct to the best of my knowledge and belief. I understand that
the acceptance of my application for the examination is based on the abovecited declaration.

     I therefore agree that in case my application is approved based on the declarations made and should a post verification of the
information supplied yield information contrary to what is declared, my application shall be disapproved and my payment forfeited.

     In addition, I agree that any misrepresentation made in this document may cause the invalidation of the result of this examination and/or
the filing of administrative/criminal case/s against me.

        Done this __________ day of _______________________, 2007.


                                                                                                  APPLICANT
                                                                                          (Signature over Printed Name)

TO BE FILLED-UP BY THE HEAD OF THE AGENCY/AUTHORIZED OFFICIAL
Note : For those occupying SG 18 - 21, if in government, and those in the private sectors only
    This is to certify that Mr./Ms. ____________________________ of this Agency/Office has been performing supervisory/
    managerial functions (i.e. directing & approving work outputs of employees; delegating functions to the staff; monitoring &
    rating employees' performance based on duly approved performance targets; & supervising the unit/division based on the
    staffing pattern/organizational structure) , and supervising/managing _____________ staff for ____________ years now.
                                                                                   (number of staff)             (number of years)




    _____________________________________________                                 _____________________________________
         NAME and ADDRESS OF AGENCY/OFFICE                                        HEAD OF AGENCY/AUTHORIZED OFFICIAL
                                                                                       (Signature over Printed Name)

OTHER INFORMATION:
1. Pursuant to (a) Indigenous People's Act (RA 8371) ; and (b) Magna Carta for Disabled Persons (RA 7277) , please answer
   the following items:
              a) Are you a member of any indigenous group? YES [ ] NO [ ]
                   If YES , please specify:
              b) Are you differently abled? YES [ ]       NO [ ]
                   If YES , please specify:
2. Are you willing to work in the Government?      YES [ ]      NO [ ]
3. If YES , list three (3) preferred Government Agencies:                          Area or Region
            a)
            b)
            c)
4. Preferred Position:                                                            Preferred Salary:




                                 IMPORTANT                                                 BRING THE FOLLOWING ON EXAMINATION DAY
                                                                                        1. This Application Receipt
  IF YOU FAIL TO RECEIVE YOUR NOTICE OF ASSIGNMENT ONE [1]                              2. One [1] blue or black ballpen
  WEEK BEFORE THE          EXAMINATION,     PLEASE VISIT OR CALL THE                    3. Lead pencil/s no. 2 and eraser/s
  REGIONAL OFFICE WHERE YOU FILED YOUR APPLICATION TO INQUIRE                           4. Valid I.D. Card with photo, signature, birthdate ( if
  ABOUT YOUR SCHOOL ASSIGNMENT. FOR NCR APPLICANTS, PLEASE                                 available), and signature of authorized head of agency
  VISIT OUR WEBSITE:    www.csc.gov.ph. FAILURE TO COME ON YOUR                            (Office/School/Postal ID/Passport/License/BIR/SSS)
  SCHEDULED EXAMINATION WILL MEAN FORFEITURE OF EXAMINATION                                    * This should be the same with the ID card
  FEE AND SLOT.                                                                               presented at the time of application.
                                                                                            * NO I.D., NO EXAM.
                                                                                       * DO NOT bring cellular phones & other materials outside
                                                                                         of those above-listed, otherwise , they will be confiscated
                                                                                         by the Security Officers. The Commission will not be liable
                                                                                         for the loss or damage of said belongings.

								
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