INFORMATION, CERTIFICATION and NOMINATION SHEET

1. Please fill out this form completely. Use black or blue ink and print legibly.
2. Submit this original copy to the DepEd-Katipunan II District-Assessment and Review Panel on or
before September 19, 2022.
I. Personal Information

Full name (MR. /MS. /MRS.)

______________________________________________________________
(Please encircle appropriate title) Surname Given Name Middle Name

Home Address: ________________________________________________________________________

Date of Birth: Place of Birth Age Gender

Mobile Number Civil Status Name of Spouse: No. of Children

Personal E-mail Add: (if Applicable) (if any)

Name of School: _______________________________Address of School: _______________________

School Level Elementary, Secondary):______________________
Please underline appropriate Position ______________________________________
(Principal-I, II, III. HT-I, II, III, IV, V, MT-I,II,III, Teacher I,II,III )

Category Joining (Please write the KRA and Objective that the nominee is joining

KRA: ________________________________________________________________________
Objective: ____________________________________________________________________

II. CERETIFICATION BY THE NOMINEE (to be filled out by the nominee)

This is to certify that I voluntary submit myself to the rules of Katipunan II District PSDS-Awards for Outstanding
Performance for Teaching and non-Teaching employees.

I also certify that I am physically and mentally fit to undergo the evaluation process of the selection. Further, I authorize
the organizers of the awards or their designated agent/s to validate the information, records, documents that I shall submit in
relation to the nomination and to use these in related activities. In this regard, I hereby exempt discharge, release and free
Katipunan II District Awards Committee, their respective Assessment and Review panel from any claim or liability arising from
my participation in the selection.

I hereby certify to the best of my knowledge and belief that all the information contained in this form is true and correct. I
am aware that any willful misrepresentation or misdeclaration of facts or any untruthful statement or information stated herein
shall be used as basis for my disqualification or the withdrawal of any award slot.

I hereby commit that should I win in the search, I will participate and attend the awarding ceremony following the awarding
guidelines.

Signed this day of ______________________at _______________________________

Date(mm/dd/yy) place

__________________________________
Printed Name and Signature of Nominee

CERTIFICATION AND NOMINATION SHEET( to be filled-out by the one who nominated)

This is to certify that I voluntarily nominate____________________________to the 2022 Katipunan II District PSDS-
Awards for Outstanding Performance of Teaching and no-Teaching employees. This nomination is a tribute to his/her track record
of excellence and exemplary performance for S.Y. 2021-2022 particular to the Key Result Area being entered that contributed to
the school development .

Signed this day of _____________________at_________________________________

Date(mm/dd/yy) Place

____________________________________
Printed Name and Signature of Nominator

Designation :__________________________________