Republic of the Dbilippines Department of Education REGION III SCHOOLS DIVISION OFFICE OF NUEVA ECLA DECLARATION FORM OF TEACHER APPLICANT Fall Name: Last Name First Name Middle Name Nationality: Se fae j Contact Number: “Email Addresi Foreign countries you have worked, visited, transited or travelled to in’ the past 14 days? : Barangay, Municipalities, Cities and Provinces you have worked, lived or transited in | the past. 14 days? 7 Have you been sick in the | 0 Yes. Describe condition No. past 30 days? Did you have any of the | 0 Yes, Please specify. oo. following in the last 14 days: | | fever, colds, cough, sore | throat, or difficulty in breathing? ls — Have you been in close | 0 Yes. Describe circumstance | 0 No. contact with farm animals or exposed to wild animals in the past 14 days? - 7 Have you secured Medical | © Yes. Name of Physician. Certificate that you are physically fit? Declaration: ‘The information I have given herein is true, correct, and complete for the purpose of teacher | application. understand the consequences of entries Ihave provided. Signature Over Printed Name of Applicant ties Il entries herein will be treated with utmost care and confidentiality for teacher application process, part of the precautionary measure of DepED Nueva Ecija against Corona Virus 2019. Tel. No.: (044) 940-3121 Email Address: nueva.ecija@deped.gouph 5: Bray. Rizal, Santa Rosa, Nueva Ecija 3101 Facebook: https//wuwvfacebook.cm/goups/DepEDNueva.djalssuances