mare Paget iis Reubicolte Pipes Segicliontatrity Cem SERVICE COMMISION Bennetts Regional Office No, Sci ee 5 Form 101€ (Revs, Apt 2012) aoe ‘ets Foa'§ nor For ste Syms REPROOUCTION 1 ALLOMED, Stan Application for Grant of Eligibility PursuanttoR.A. 7160 wnat (Barangay Official) Sicamnnonangae _ Ee INSTRUCTIONS Fine equtedforan Pun for tems nol appleableto ou Subthis Fom,tgsher wth ocr irene, foe CSC Regio Fa fic cocoa Ne. Tha Foray accomplished aerate, pew congue, rowed hate sre ote apo chal andre, Digitaiscanned signature is strictly not allowed.) ‘APPLCANTS NAME: 2. MOTHERS MADENNAME: i — = ~_ =_— ‘3, COMPLETE PERMANENT MAILINGADORESS: ZIPCODE. 4.SEXquny,___8 DATE OF SRTH ametnny:________ 6 PLACEOFBIRTH Opmancoy rove, 7. CIVIL STATUS: O Single O Married © Legally Separated Q Annulled © Widowed © Others, specify 8. CITIZENSHIP: 91. NO: JO.CELLULARPHONENO; 1, EMAILADDRESS ‘2. EDUCATION Highest Eucatonal Atainment) Level of Eduction: © Elementary High School © College © Master's © Decale Completion: © Graduated ONolGradvated — lnotaraduate, highest GradaearLereWUnis eared roduated date of Gradualor'Completon any Honors recived Complete Tite of CourselDegee fk. nas a —_ Mejor Narre 8 aires cf schol tended: Incushe years 13, EMPLOYNENT (Present & Previous): " Agenylce Aetess Psion Tile Silus fAppEmployrent cy Years Gov Seyi? 14 Barangay Senor nimation = ~ Barangay iyi. Province Posnted______DaeofSeconiAppoiiment_____ncushedeschampltedtemot oi From To 15 Oher Eighties: Tet Eigity 1) _ Date of Cotemment = 2 | decare underoath hat personally aocorpised tis Formate infomation given aoe, cect and complete sttements pursue poisons ofprtnet lass an requlaons the Repti Pippnes.|understnathal ay mieresniation mace inthis document shal cause theisaprovalf my appicaion and cutght revocaon ofthe elit gran without prucceothefling of adninistavelrininalcasels aganstire. Donets dy Sonor sow As Ne Sigal ove lined vane ofthe apicant Sutscbatandsvombbelore mets ayo a Sige over pied nae ot Aaritng Oia fication INDORSEMENT (CSCFO to CSCRO or CSCRO o GSCCO; Toe fils p ONLY os apace: ENOORSING the apicatn of te S60 No, CSCO asteeivebyCSOFO- / CSCRO No. n {orapprol andprocessng fhe antl Barangay Oki elgity. ‘Signature ver fll pinted name of CSC FieldRegional Drecor Date [ACTION TAKEN (for Processors on) © Approved © Disapprovedsueto © For Compliance forms foe | Theor agtity Dat of ety nt lose (ae: Cetfcate of Egy No, Seta No. Remats. = es es | Signature over tl + Seaueoret [APPLICATION RECEIPT ‘Signature over full printed name of Reosiving OtfoerDate(Fee 8 Poenot On |. QUALIFICATIONS FOR THE GRANT OF BARANGAY OFFICIAL ELIGIBILITY (BOE) 'A. Checkist of Qualifcations Qt. EWctie oft © Punong BarngayBry.Capain © Bry. Kagowad/Counclr © SK Chaiman Spec indus dats of compaed tom of ofc: From fin. To (nmin 2 2 Apponive fia: O Bry. Treasurer Bry. Seca Spec indie dats fom of ofthe conced acpaningPunong Barangay. Frm ret). Toren 2 3, Compl the tam of fen sped by te pean aw (or eect ofdaliearespondng to tie appa Purong Barangay (or eppaive Oa |G. 4. Name of appar is ined in the coresponcing astr Ls sued by he DILG fice concumad 'B. Evaluation on Qualifications forthe Grant of Eligibility Qualified (a quatcatons stare met. Appiaon for approval © Not auld. Appeaton for disapproval. Spec qualfcatons not met __ I. DOCUMENTARY REQUIREMENTS FOR SUBMISSION (To be accomplished onl for qualified applcatons; Put ates (for lcking tims andor “nor hems not applicable) |A. Checklist of GENERAL REQUIREMENTS: {Q "1. Propet ecampned CS Form 107, Revsed Ap 2012 a fs property les out, wth "a" indicates in a8 fds not appleable te eplicen) 2 Tree (2) pce of ont roan! LD laure wi the flow spesiatan: Papa sonx3ser) G nvetetoagae 1. Pedenquity tmp 1 intwetsjwtnsegectkensort ny al ce ahve nave) 0 Shove {Gna csp ata ro shou vy wad nice ping els Wf pee dwn are pote cal tw) vid wie ono ge xen Rosa sadat aoe rdrane hte are stare Msn atNonesersenhare NOTE DONDTACCEPTLD PCTUREF NOT WTHALL OF THEABOVE GFEFICATIONS 13. Oil and pot of ay of he owing cards, which must be va tt exe) upon fing applica, and bears the apicants nae, picture and sgt, ard the tug fers nae and signature (NOTE: Ary oer ID. card NOT included in te Ist shal NOT be acrpled. Cd the LD. cas subi by he eppkat + amt Oe Carpay 0. *oasuMD "Pisa D (ATW) 1 Shei (matte sy test ecanenseht ya + ss510, aero + Pasiptiahsizaet be erica) 1 Pree Pans. + BRID.ATMypetanraledeaswnpetae ys) 1 Diaries + BaaiD + Pacaceazcs wp) rina ane petocopyo Bit Cette othe applicant auontcatelzaved yf NSO lo ncn he NSO Er Cates na wl, ot NSO ya a Raat ‘Graton NSOCRSFom No NSO ec ema shal.v atnbitbo ere rhonda PC Ratan) 5. Frfemale mare appa, egal nd pocay of Mariage Corie auboncaadisued by he NSO ok: nob NSO Mang Cotes iat i, eaten ‘hal nan tet fg on hot ae Varoge Cae asbertass oP Raptar) 6 Ceioaton erect bye aplcat at ashe nas no pending ana andr cima case blo any countautoze body, nd that hafshe has never been ‘ound guityeoniced of ay adnate oflens ardor cine, using the prosirbed CSC SPEL Fon 1, Apel 2012 7 ing appa & frou a represent: C Autatzalon ti exec by tw apicart ard. Oral and phoacpy oo) vad ID. ado be esr. . Checklt of SPECIFIC REQUIREMENTS: Barangay Official Eligibility 1. Coflflesion from auhoraed DILG offi tthe municgal, ty, provincial or resional vel ofthe services rendered by the barangay of, using the prescribed ‘CSCERPO BOE Form tle), Api 2012, for elcive barangay ofical, or CSC-ERPO BOE Form 1(), Apel 2012 for apponive barangay oils 2, Cericaton rom the Barangay Choiman onthe seizes rendered by the barangay ofc 3, Dut sgn cahaking crite ober ros of having been duly elected or poo suchas election eur and appoinimert paper Noted ASiavt stag Bal te barangay ofl was nt eloyed inthe goverment durng her tm fof, or sence eqirement and at hash ct ot recive ay frm of salaylsompersaicn, except honradum for had a poston in an exo capct, cng hishe term office or sonic requrerent 5, For appointive barangay offal (Barangay Saclay & Barangay Tete notaraed ARéa slang tte apoiive barangay ofa snot rela up 0 the ‘th ogres of consarguiy oro afi, 0 he apporing Punang Barangay 6, Ofgalutensate and! ty ele Mast Lis of Ecostore Guang Ofoas sued by fe DLG (agency agerey cane; be sub by DILG t» CSCRO) 7. Ofer documents as may be seemed necessary bythe CSC Regional Ofce in vrtyng authenticity of formation supped by the barangay ofl C. Evaluation on Documentary Requirements Submited © Complete doaumens ‘© Ineampetotackng documents, See tens in fe above checklists mated weh aston ("fr compliance © rearet doeuents. Spectydelenoyes eee Spec eguses to adcess the defcencyles eee (© Data en documents wih dscrepancyies Spec discrepancies pect equities to adres he dsarepenoyes eo) oo oo © ooo oO ‘Signature over ful pried name of 1 Processor ‘Signa over fu printed name of 2 Processor Doe __ Peston Date _ Pion [CERTIFICATION (To be accomplished onl fo quaited applicants wih comple docurent) We cry that we have evowed the quaifcatons and al he documestary equreents submited by on hisher lca or grant ofthe Barangay Ocal eigbily, and urd te same fo be complete and in ere Sit a pare o Fame Satan oer pr neo Pre oe eaten eh CERTIFICATION (Tobe socompshed ony ypan submission of AL documents fr complincarguistes addressing defences andor discrepancies): We cert that has submit on ‘the marked documents for complancakequses adcesing marke deienes andor Gacropandes, We Tutor cay 1 have revewod the complied docurentsFoqusies and found the same tobe stsfacty and inorder ‘Sinalre over fl pind nae of 1 Processor ‘Signature over full printed name of 2* Processor Dat Peston CSC Regional Office No. may be reached at CSC Field Office may be reached at the following contact numbers: the following contact numbers: Telephone Telephone Cellular Cellular Fax Fax E-mail add E-mail add Contact Person Contact Person