Republic of the Philippines

Department of Education
Region VI – Western Visayas

_________________
Date

CERTIFICATION

I __________________________ of legal age, residing at _________________________

hereby certify that I am not related by consanguinity or affinity up to the fourth
civil degree to the head of the agency/appointing authority/recommending
authority or members of the Personnel Selection Board (PSB) of the DepEd
Division of Roxas City, who directly took part in the selection and ranking
process nor I will be assigned in the office or department where I will be under
their immediate control and supervision.

That I am making this certification in compliance with Section 79 of R.A 7160

in relation to my appointment as ____________________________________________.

_______________________________
(Signature over Printed Name)