ot xaponeete ones) Repubic lho Pilpines ‘reaittremprtect CIVIL SERVICE COMMISSION nto sata Region Ofice No, Fete area! ‘obelor te 6S Fo 104 (Revs, Dee. 2011 ‘Sosy ester ‘THIS FORM IS NOT FOR SALE. Shwe REPRODUCTION IS ALLOWED. Sober Application for Grant of Eligibility Purouant to R.A, No. 7883 tence f (Barangay Health Worker) Soran i INSTRUCTIONS: Filinthe requtedivoration. Puta” for items notapplieableto you. Submits Form, ogether wih the documenta equiemeis othe GSC Regional! Fel fice concemed Noe: Tis Form may be acomlsed ther hancwiten, ype, or comput printed, provided hat he signature othe appicat shouldbe handuriten, Digtalscanned gnats sity not alowed) {aFPLOATSNNE = "es es are a 2 MOTHERGMAENNE me a fe 2 COWPLETE ERUMMENT ALNGAGORESS cd 1.52%; SOATEOF TH pay S PAGEOF RTH Guay i T.CIVIL STATUS: © Single © Married © Legally Separated © Annulled © Widowed © Others, specify _ ‘8. CITIZENSHIP ee ‘0. CELULARPHONENG EARS 42 EDUCATION Highest Educational Ataament) Lovel of Edwcation: © Elementary © High School © Colego © Master's © Doctorate Completion: © Graduated © NotGraduated —lLnotradualed highest GradeYearl-evelUnits eae: laradualed date of raduaion!Completonfmistymg,__ Honors received: Complete Tie of CourselDegree cae mets, dtr Na Name &axressofschool tended Indie year 18, EMPLOYMENT (Present & Previous): ‘Agenyfice cores PsioniJob Tie ‘Status ofAppLEmployment Ince Years Gov't Savio? 14, Barangay Sovice fomation Barangay Cynic. Province, "No.of years served as BHW, Inctusie dates: From amity Tojwmsiinn, 18.OherBigtiiyies: TecfBigbity #) ate Conform isi 2 \ cre underoath personally axconplshed his For, anal foraton gen atu, cored and cont siemens usa! othe provisos of petnent love, lesendreqdatons ole Repub the Pipes | undetond hat ny rixereseriten madeinbis docunert sha asethedsappoval fy aplcatin andro. revocabonctheelilly ranted winout rjuscoothefing of adminll casas agains ma. Danetis dayal. 2, ‘ovr FUL EeLON TSUN ‘Signature over tll pniedname the appeant—_ Sutscrbedandswomtabetremetis, day. a, ‘Signature oer l prined name ofAdrinisterng Offcar INDORSEMENT (CSCFO to CSCRO or CSCRO to CSCCO; Tobe filed up ONLY as applicable): ENDORSINGtheappicaionof to CSCRONe,_/CSCC0 asecsivedby CSCFO., (CSCRONe,__on, ‘or approvaland processing the grant of Barangay Heath Worker eit. “Signature over ful pinted name of CSC FieldRegjonal Director / Date [ACTION TAKEN ('or Processors only 2 Approved © Dsepproved veto 2 ForComplance aaa STAT ETE jorns——_|lonm: TWectBigbily at tet ri), jose: ______ | 0ae__} Certificate of Eligibility No, Serial No. Remarks, feos ——— lhe = | a TT jonm_|lonwx APPLICATION RECEIPT are, fost ono | Rattan Tees sent. paar i Tone aoe a ae ‘tialutzeompeaton Sncimpeneatcearety Gana ica ~ || “aca a of ely under pei lans & CSClssuaces at CSCROFO. cee ee Cantona oa Seopa rp ee er are ovr fl pied name of RecevingOfcedDale ator = os ‘cortege sbi rare emcheneenoa NOMor cc Pees ny) |. QUALIFICATIONS FOR THE GRANT OF BARANGAY HEALTH WORKER (BHM) ELIGIBILTY A. Checklist of Quaifeations (G'.Acrsed BH a cere byte Loa Heath Boa and fe Barangay Heh Wr Regoton ard Aceon Cone (cen mist be no ere th sat of be fveyar ora sevice) (2. Ranred at ast re yeas of rian, coiruos and scary sve os on ocdid BH he connunly a cts bye Loca Hes Soars Spec nse dates From (nmin) ————— To (nmin) 3. Competed a est wo your of colge eta ad a caope doyee 4. Name of apecant is ned nthe corespnng DOH-ssod Regt of Acted BAY '. Evaluation on Qualifications for the Grant of Elgibilty © Chad (a qualitaons stare med, Aplcaton for approval (© Wot uated Aopzatn for disspprova. Specy quis not met |, DOCUMENTARY REQUREMENTS FOR SUBMISSION (Tobe accomplished ony fr quale applications; Put asterisk (for ching items andor “for Hems not applet) A. Ghechlst of GENERAL REQUIREMENTS: ‘Ot. Property ecoompishes CS For 101-4, Revsed De. 2011 (al ets proper fled ou, wi ‘la indicted in al els nol apoabl to tho aplican) 2. Tree pees of dental recent. pictues wih the lowing specie: (Passo sis sem x25 en) 1 in wi backround {Pind on cuaty photo paper 1 inberetac toes sseesies tly ao azo acalene neonpve etc) {Showing lt and gt as ‘Dinstnian oon shel fon ein wn tt toceay sens te pei wth Fane etal ana he ee {Win ane ac wien cpa, ar egbie name showing sonar er come ed nane Nf foma rs Nar Me i act Name xs Name NOTE: DO NOT ACCEPT LD. PICTURE IF NOT WITH ALL OF THE ABOVE SPECIFICATIONS |. 3. Orginal ans photocopy of any ole olin LD. cas, which rast te veld (not xe) uron fig of aplcaton, and bear the apikants name, cur an spree, and te issung ofr name ad sri (NOTE. Any chr LD. card NOT ico in the let shall NOT be aco Co fo ID. card ute by the appa ‘+ Curent Ofica/Campany 10, + 688 UMD ‘+ Phiveath LD. ATM pe) + Schoo! LD. (ust be dy vaiated forthe curent stool yea) «+ S880. + Votes 1D. ‘+ Passprt (wi Sonate ofthe apotcat) + PRC Linrse + Post LD. ‘+ BIR LD. (ATM ypetaminated card wih picture ype) Divers Lense + Barngay 10, Poles cearance (wih pice) 2. 4. Orginal ns photocopy of ith Cert lhe applicant aubenialdissed by fe NSO Ns: ncae he NSO Br Cee ino eb, be NO hes ye a Nepat (eiesontth SOC Flom pina NSOsoaiyom Sealants nai bn acid rd pene anche BC aenscosksy eal Ol epee 5. Fortemae mame applicants, cxginal and photocopy of Warrage Cacate auteriicatadissued by tho NSO (cs case Re NSO Maras Cr srt, te lent ‘Stal. adn sib engl nap ar rig ete asennad Cl ape) 6 fing of apleaton trough represeiatve (2 Auhorzaton iter executed by he appleant and Crgnal and photocopy of oe (1) vl 1D. cad ofthe representative, Checklist of SPECIFIC REQUIREMENTS: BHW Eligibility 7, Schoo eticale or Lancto of reco [applcant must have competed atleast wo 2) yer of exloge efucaton lead oa clege dere) 8, Cerca of Aczedtaion sued and saned bythe chakan or auorzed ofa of ie Barangay Heafh Worker Registafen and Acrdtaon Commitee ant ofthe Local Heath Boat (he Corse of Aozedaton must hve bean laved ono afr the stat af th e-ear voy see) 9. Caricaton oft leas fv (5) years of continuous ad satisfy sarice as an acceded BHW ssud by to Local Heath Boar “0. Notaraed AMidavt sang that he BH was not erployed in fe govemment crn rsher serie requires, and that hashed not reese ay for of sly! ‘omgensaon, except honorarium, dng hisher sence requirement 1. Aubencatodcrii’ copy of Anal Aezimpshnent Repos 12 Oiginalauhenteated and dy-seled Regis of Actedted BHU ised by DOH (apeny to agen conn bbe subted by DOH to CSCRO) alution on Documentary Requirements Submitted Complete documents Incompleetadking documents. Soo ams in the above checks marked with ast (fr compliance Incaect documents. Spey deencyies Spaciyrequsiels to adsiess the deengas Data on documents with dscepancyis, Speciy dscepanoyes Spectyrequsie's to aisies be Uscepareyles o © coog co oo ag ‘Snare oor ful pind name of Processor ‘Sra oer pred rame of Processor Doi Pein sea ate OM ar CERTIFICATION (Tobe accomplished only for quaied spplcnts wih conglte documents: We cry that we have reviewed te quaifcatons and al the documentary requrements submited by ner ppaton for gato the BH egy, and found he samt be compl ad inode. ‘Signature over lpi name of 1" Prooessor ‘Snare over ul preted rare ot 2 Prosessor Dale Peston Date Psion ‘CERTIFICATION (Tobe accompished ony upon submission of ALL documents fr complancerzuises adtresshg defences endo ascrepnces We cei that_______ has sutmed on_______the mated docurents for complancalrequttes adeessng marked defences andor dacrepandas. We fur cay 1 Rave reviewed te conples omer and Yound he same to be setsecny and in ese. ‘Signature ove fl pried name of Processor ‘Signature over flpasrame of 2° Processor Dee______ Poston Date Poston 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 Email add: E-mail add Contact Person: Contact Person