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  2. One  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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