REPUBLIC OF THE PHILIPPINES )

CITY OF SAN CARLOS CITY ) S.S.

OMNIBUS SWORN STATEMENT

I, , of legal age, single / married, and resident of

Barangay , , after having been
duly sworn in accordance with the law, do hereby depose and say:

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

Committee:
a. Letter of Recommendation by the School Division Superintendent
b. Total number of teachers in the District
c. CSC Form 212 with its supporting documents such as:
 CAV Transcript of Record
 Updated Service Record
 Certificates of Trainings (Latest)
 Report Ratings
d. Performance Ratings for the last 3 years Certified Correct by the Principal,
signed by PSDS and noted by SDS (Certification
e. Name of School / District Assignment (Certification)
f. Rank List for the Current School Year must be in Accordance with MEC Order
No. 10 s. 1979 and other existing guidelines
g. Proposed ERF for Master Teacher
h. Plantilla Allocation List
i. NBI Clearance (Not Expired) and,
j. This Omnibus Certificate

2. Each of the documents submitted is in satisfaction and compliance with the

requirements for recruitment set by the Department of Education;
3. Each document is an authentic copy of the original, complete, and all data /
information therein are true and correct to the best of my knowledge and belief;
4. I assume responsibility and accountability on the validity and authenticity of the
documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this day of , 2020

in San Carlos City, Philippines.

Name / Signature of Application

SUBSCRIBED AND SWORN TO before me this day of , 2020,

affiant exhibiting to me his / her Community Tax Certificate No.
issued on in , Philippines

Doc. No.:
Page No.: