REPUBLIC OF THE PHILIPPINES

CIVIL SERVICE COMMISSION

QUEZON CITY
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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. 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 _____________________________

MAJOR FIELD OF STUDY ________________________
DATE GRADUATED _____________________________
SCHOOL GRADUATED __________________________
SCHOOL ADDRESS _____________________________
10. GOVERNMENT SERVICE RECORD
POSITION

11. CIVIL SERVICE/BOARD/BAR EXAMINATION PASSED

RATING

HIGHEST YEAR IN COLLEGE COMPLETED ______________

COURSE ___________________________________________
NO. OF UNITS EARNED ______________________________
INCLUSIVE YEAR ATTENDED _________________________
SCHOOL ATTENDED ________________________________
SCHOOL ADDRESS _________________________________
STATUS

OFFICE ADDRESS

DATE OF EXAMINATION

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 ____ DATE ____________ SIGNATURE ___________________

OR NUMBER ________________
DATE ______________________