Republic of the Philippines

Department of Education
DepEd Region VIII-Eastern Visayas
SCHOOLS DIVISION OFFICE OF SAMAR
Office of the Schools Division Superintendent
Enclosure 2 Division Memorandum No. 194, s. 2021

Republic of the Philippines

_____________ ) s. s.

OMNIBUS SWORN STATEMENT

I, of legal age
(Name of Affiant) (Civil Status)

, and residing at
(Nationality) (Address of Affiant)

After having been duly sworn in accordance with law, do hereby depose and
state that:

1. Each of the documents submitted in satisfaction of my application for

teaching position is an authentic copy of the original, complete and all
statements and information provided therein are true and correct.

2. I am authorizing the selection committee or its duly authorized

representative(s) to verify all documents submitted as to completeness and
authenticity.

IN WITNESS WHEREOF, I have hereto set my hand this _______ day of

_______________ 2021 at __________________________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _______ day of _________________,

2021 in _________________________________. Affiant exhibiting to me his / her
valid identification card - _______________________________ issued by
____________________ at ____________________.

Doc. No _________
Book No. ________
Page No. ________
Series of ________
 Republic of the Philippines
Department of Education
DepEd Region VIII-Eastern Visayas
SCHOOLS DIVISION OFFICE OF SAMAR
Office of the Schools Division Superintendent
Enclosure 2 Division Memorandum No. 194, s. 2021

Republic of the Philippines

_____________ ) s. s.

PRE-SCREENING CERTIFICATION
(School Selection Committee)

To Whom It May Concern:

This is to certify that the School Screening Committee of

School, District, has
evaluated the authenticity and completeness of the documents for application to
Teacher I position of with the
following documents presented to the School Screening Committee, to wit:

CSC Form 212 (Revised 2017)

Certified photocopy of PRC license
Certified photocopy of ratings obtained in the Licensure
Examination for Teachers
Certified photocopy of the General Weighted Average from the
School Registrar
Certified photocopy of the Transcript of Records
Copy of the Service Record, Performance Rating, and School
Clearance for those with teaching experience
Certificates of specialized training, if any
Certified true copy of voter’s ID
NBI Clearance
Omnibus certification of authenticity and veracity of all
documents submitted, signed by the applicant (see annexed form)

Issued this day of , 2021, at

School, District, ,
Samar.

SCHOOL SCREENING COMMITTEE

Member Member

Member Member

School Head/Chairman