Republic of the Philippines

Department of Education
CARAGA REGION XIII
SCHOOLS DIVISION OF SURIGAO DEL NORTE
(Enclosure 3)
CHECKLIST OF REQUIREMENTS

Application Code: ____________

Name of applicant: SUPANGAN

_______________________________________________
JESANI DUMALAG
Last Name First Name Middle Name Suffix
Education level applied for: Kindergarten/Elementary ( / ) Junior High School ( ) Senior High School ( )
If Kindergarten/Elementary, for which school/district? _____________________________
MAINIT II
If JHS, indicate subject area of specialization: ___________________________________
If SHS, indicate track: _______________________________________________
College degree: _______________________________________________
BACHELOR OF ELEMENTARY EDUCATION
Graduate studies:
(indicate number of units earned) __________________________________________________________
Contact number(s): _______________________________________________
09633188388
E-mail address: _______________________________________________
jesa.supangan@gmail.com
Ethnicity: _______________________________________________
FILIPINO
Person with disability? Yes ( ) No ( / )
Solo parent? Yes ( ) No ( / )

Status of Verification
Submission Status of Remarks
Basic Documentary (to be filled out Submission (to be filled out by the
by the applicant; (to be filled out by
Requirements check if the AO II; check if HRMO)
submitted) complied)

1 Checklist of Requirements with Omnibus

Sworn Statement on CAV of the documents
submitted and Data Privacy Consent Form
2 Letter of intent addressed to the Schools
Division Superintendent
3 Duly accomplished Personal Data Sheet
(PDS) (CSC Form No. 212 Revised 2017)
and Work Experience Sheet, if applicable
4 Photocopy of Scholastic / Academic Record
e.g. Transcript of Records (TOR) and
Diploma from CHED-recognized
institutions
5 TOR / Certificate for graduate / post
graduate units/degrees earned, if applicable
6 For SHS-TVL applicants, National
Certificate II (NC II) issued by TESDA
7 For SHS-TVL applicants, Trainers
Methodology Certificate I (TMC I) issued by
TESDA
8 Photocopy of certificate(s) of training, if
applicable
9 Photocopy of Certificate of Employment,
Contract of Service, or duly signed Service
Record, whichever is/are applicable
10 Photocopy of Latest Appointment, if
applicable
11 Photocopy of valid and updated PRC
License / ID, if applicable

Address: Peñaranda St., Surigao City

Telephone: (086) 826-82-16
 Republic of the Philippines
Department of Education
CARAGA REGION XIII
SCHOOLS DIVISION OF SURIGAO DEL NORTE
12 Photocopy of Certificate of Eligibility /
Report of Rating, if applicable
13 Certified copy of voter’s ID and/or proof of
residency as deemed acceptable by the
HRMO
14 Other documents as may be required, such
as but not limited to:

Photocopy of the Performance Ratings in

the last rating period(s) covering one (1)
year performance prior to the deadline of
submission, if applicable

Checked by:

_____________________________
Name and Signature of AO II/ School Head

Attested:

RACHEL JADE D. FELICITAS

Human Resource Management Officer

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OMNIBUS SWORN STATEMENT
CERTIFICATION OF AUTHENTICITY AND VERACITY

I hereby certify that all information above are true and correct, and of my personal knowledge and belief, and the documents
submitted herewith are original and/or certified true copies thereof.

DATA PRIVACY CONSENT

I hereby grant the Department of Education the right to collect and process my personal information as stated above, for
purposes relevant to the recruitment, selection, and placement of personnel of the Department and for purposes of compliance
with the laws, rules, and regulations being implemented by the Civil Service Commission.

JESANI D. SUPANGAN
___________________________
Name and Signature of Applicant

Subscribed and sworn to before me this ____ day of __________, year _____.

Person Administering Oath

In consonance with Republic Act No. 8792 or the “Electronic Commerce Act of 2000”, (e)lectronic documents shall have the legal effect, validity or enforceability as
any other document or legal writing and a) (w)here the law requires a document to be in writing, that requirement is met by an electronic document if the said
electronic document maintains its integrity and reliability and can be authenticated so as to be usable for subsequent reference.

Address: Peñaranda St., Surigao City

Telephone: (086) 826-82-16