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Republic of the Philippines Republic of the Philippines

Department of Education Department of Education


Division of Northern Samar Division of Northern Samar

(Screening Committee Copy) (Screening Committee Copy)

Teacher 1 Application Requirements per DM Teacher 1 Application Requirements per DM


188, s. 2021. 188, s. 2021.

Name of Applicant: Name of Applicant:

(Surname) (First Name) (M.I.) (Surname) (First Name) (M.I.)

Please mark ✓ if the requirement was submitted Please mark ✓ if the requirement was submitted
and mark x if the requirement is missing. Advise and mark x if the requirement is missing. Advise
the applicant to complete the requirements prior the applicant to complete the requirements prior
to its submission to the Division Office for final to its submission to the Division Office for final
evaluation. evaluation.

Elementary▢ Elementary▢
Secondary▢ Secondary▢
Specialization if Secondary ________________ Specialization if Secondary ________________

▢Application letter ▢Application letter


▢CSC Form 212 (Revised 2017) ▢CSC Form 212 (Revised 2017)
▢Transcript of Records (TOR) ▢Transcript of Records (TOR)
▢Authenticated PRC Professional ID Card ▢Authenticated PRC Professional ID Card
▢Authenticated PRC Certification of LET Rating ▢Authenticated PRC Certification of LET Rating
▢Certificated of Training Attended after ▢Certificated of Training Attended after
graduating graduating
▢Service Record with Certificate of employment ▢Service Record with Certificate of employment
▢Performance ratings for the last three (3) rating ▢Performance ratings for the last three (3) rating
period period
▢Voter’s ID (for Elementary Teacher Applicants) ▢Voter’s ID (for Elementary Teacher Applicants)
▢Certificates of specialized training (if any) ▢Certificates of specialized training (if any)
▢National Certificate I and II Training (if any) ▢National Certificate I and II Training (if any)
▢Trainers’ Methodology Certificate ▢Trainers’ Methodology Certificate
▢Duly Notarized Omnibus Certification of ▢Duly Notarized Omnibus Certification of
Authenticity and veracity of all documents Authenticity and veracity of all documents

CERTIFICATION CERTIFICATION
This is to certify that the School Screening This is to certify that the School Screening
Committee has received, checked and verified Committee has received, checked and verified
the above documents for authenticity and the the above documents for authenticity and the
applicant has been found to be qualified to applicant has been found to be qualified to
undergo further screening/selection process by undergo further screening/selection process by
the Division Selection Committee. the Division Selection Committee.

DIANA FLOR D. ECO DIANA FLOR D. ECO


Chairman, School Screening Committee Chairman, School Screening Committee

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