ࡱ> XW \p John Alcaraz Ba==;!8X@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1xArial1.Times New Roman1.Times New Roman1.Times New Roman1.Times New Roman1Arial1Arial1.Times New Roman1.Times New Roman1Arial1Arial1.Times New Roman1.Times New Roman1.Times New Roman1.Times New Roman1Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)"P"#,##0_);\("P"#,##0\)!"P"#,##0_);[Red]\("P"#,##0\)""P"#,##0.00_);\("P"#,##0.00\)'""P"#,##0.00_);[Red]\("P"#,##0.00\)72_("P"* #,##0_);_("P"* \(#,##0\);_("P"* "-"_);_(@_)?:_("P"* #,##0.00_);_("P"* \(#,##0.00\);_("P"* "-"??_);_(@_)                + ) , *                (            (@   (   (   (   ( @   (   (           (@      (  (  (@@  (@  (@  (  @  (@  (  (  ( @  (  (  (     "     ,   ( "  ,@@  ,@  (@@    (   (  (@  ( @   `#`ACS Form101-A (Revised 2005)ySheet2 Sheet3  ;8bZ  $G3  @@ @ APPLICATION FOR GRANT OFELIGIBILITY UNDER SPECIALLAWS & CSC ISSUANCESTHIS FORM IS NOT FOR SALE. REPRODUCTION IS ALLOWEDINSTRUCTIONS TO APPLICANTS:?7. SEX _____________ 8. CITIZENSHIP _____________________(9. EDUCATION:XFOR GOV'T EMPLOYEES : ARE YOU INTERESTED/WILLING TO TRANSFER TO OTHER GOV'T AGENCIES? YES NO:(1) ______________________________________________________:(2) ______________________________________________________:(3) ______________________________________________________ belief is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.3 ________________________________________ Signature of Applicant)_________________________________________" ADMINISTERING OFFICER"__________________________________$ Office/Position! (PRINTED NAME/SIGNATURE)kTITLE OF ELIGIBILITY_______________________________________ DATE OF EFFECTIVITY _________________________jCERT. OF ELIGIBILITY NO. ____________________ SERIAL NO. ___________________ REMARKS ____________________ APPLICATION RECEIPT To Whom It May Concern:Y This is to certify that ____________________________________________has applied for rev101-a05j grant of special eligibility with CSC Regional Office No/CSC P.O./ F.O. ___________________________.0 Republic of the Philippines' CIVIL SERVICE COMMISSION, Quezon CityCS Form 101-A (Revised 2005)VETERAN PREFERENCE RATING (VPR)HONOR GRADUATES (PD 907)SPECIALIST (CSC RES. 90-083) (PD 997)4 SCIENTIFIC AND TECHNOLOGICAL SPECIALIST B1. Duly certifiel service record or certification of employment;%2. Transcript of Records and Diploma3. List of subject taught/being taught indicating the course number, descriptive title of subject, duly certified by the Dean or any school college or Graduate level, include only subjects relevant to the desired eligibility.4. Other document such as:*Published research and progress reports for concluded scientific reseach and progress. The reports shall be certified true copy by authotorities to whom the originals were submitted.*Certification of Research proficiency which indicates title of scientific research project/s the applicant has participated in, the duration, nature of participation and/or responcibilities of the applicant in said reseach project/s. 3pcs. (1x1 pictures)SFee : 150.00 processing fee. (exclluding the fee that may be charged by the DOST)Processing Time :Z10 working days after the receift of the request and submission of the required documents.Where to File Application :< To be filed with the DOST Secretariat, Taguig, Metro Manila EDP: or authorized official of the Barangay Health Worker < Registration and Accreditation Committee and the Local B1. Original and certified copy of the Certificate of Proficiency @ LIST OF DOCUMENTARY REQUIREMENTS FOR SUBMISSION:% BARANGAY OFFICIAL (CSC RES. 93-3666)-_____________________________________________0________________________________________________ vin0322005_10. For Barangay Official / Barangay Nutrition Scholar / Barangay Health Worker Applicant :B years authenticated by the Nutrition Action Officer concernedD Nutrition Action Officer concerned and attested by the District( City Nutrition Program Coordinator;" as BNS in the last two years.A 1. Properly accomplished Application Form and Verification Slip VPR shall be applied. Major Field of Study/Area of Specialization (If any): ____________________________________________ Date of Graduation______________________________ Name and Address of School Attended _________________________________________________________________________________________________ Brgy /Zone Nos. _________________________________________ Municipality/City __________________________________________________________  Surname0 Given Name Middle Name\Subscribed and sworn to before me this _____________ day of ____________________, 20______.3Signature over Printed Name of First Processor/Date7 Signature over Printed Name of Second Processor/Date 4. DATE OF BIRTH _______________________ 5. PLACE OF BIRTH _______________________________6. CIVIL STATUS: _______________0Bbu11. For MC 11, s. 1996 Applicant (Category 1) : TESDA Test Passed_________________________________________________________________1 Position Held _____________________________________________Year elected/appointed ______________________ No. of Years in the Service__________ Date of Test Passed ______________________ TESDA Certificate No. ________________________________ TESDA Registry Code: ____________________K Foreman, etc). Submission of a Skill Certificate issued by TESDA upon H passing a skill test, and letter-endorsement from TESDA (if Registry@ of Workers Tested and Certified(RWTC) is not yet available).C2. Category II (e.g., Laboratory Technician, Well Driller, WeatherH Observer, etc). Completion of one (1) year very satisfactory actualC work performance under temporary status; and upon submission ofA original and photocopy of the temporary appointment and other relevant documents.N1. ELIGIBILITY APPLIED FOR: Honor Graduates (PD 907)5Memorandum Circular 11. S. 1996 (SCEP) Category I, II? Barangay Official (CSC Res. 93-366)C Electronic Data Processing Specialist (CSC Res. 90-083) 2. APPLICANT S PRINTED NAME: SURNAME FIRST NAME (include ext name:Jr/Sr/IV) MIDDLE NAME MAIDEN NAME, IF MARRIED3. COMPLETE MAILING ADDRESS _____________________________________________________________ Zip Code _____ Tel. No. ______________ku'12. For VPR: Name of the Veteran : 14. EMPLOYMENT PREFERENCES: /13. OTHER ELIGIBILITY (IES) OF THE APPLICANT: _Original and photocopy of at least one (1) Valid ID with picture and signature of the applicantbThree identical 1" x 1" pictures with name tag taken within three months before the date of filingof the application.@ 3. Affidavit of Waiver: to be executed by the Veteran, if still> living or Joint Affidavit to be executed by the veteran's3 4. Death Certificate (DC), if veteran is deceased? 6. Photocopy of Report of Rating in the examination where the4 (to verify the applicant's examination result)B2. Certificate of Accreditation issued and signed by the ChairmanB3. Certification of at least 5 years continuous and satisfactory = 2. Certification of Veteran Status (CVS) to be prepared and? 5. Marriage Contract (if applicant is spouse/female-married  child of the veteran) and( (Husband/Wife/Daughter/Son) (mm/dd/yyyy) General Requirements :Specific Requirements :7 Signature over Printed Name of the Processor/EvaluatorCNote : Please see Back Page for list of documentary requirements Receiving Officer/DateVeteran Preference Rating (VPR) (EO 132/790) Relation to the Veteran: ____________ Eligibility Applied For : ____________________________ Original Rating : ____________I declare under oath that this application has been accomplished in good faith, verified by me and to the best of my knowledge andI am fully aware that any false statement made herein will result in disqualification from entering or re-entering government service,B1. Certification from the Municipal, City, Provincial or Regional; DILG officer of the services rendered in the barangay;C1. School Certif<icate or Transcript of Records (the applicant mustE have completed at least 2 years of college education leading to a Health Boards;4 service as BHW issued by the Local Health Board;H Note : in issuing the certification, it may be necessary for the LHBG to require the BHW to present proofs of services duly authenticated< by the Rural Health Midwife (RHM) or NGO representative B concerned and attested by the Punong Barangay or the Chairman,A Committee on Health, Barangay Council of the barangay/s where% the BHW rendered health services.J1. Certificate, transcript of record, or any other authentic evidence of & completion of education required;? for services rendered from January 1, 1981 and thereafter;? Copies of BNS performance evaluation sheets for the last 2?2. Copies of monthly accomplishment reports (NNC Form #5) for D3. Certificate of continuous and satisfactory service as BNS by the<4. Copies of Memorandum of Agreement or Contract of ServiceC the last 2 years authenticated by the Nutrition Action Officer? concerned, for services rendered from January 1, 1981; or college degree); System Analysis and DesignD Computer Programming such as : JAVA; MS-ACCESS and VISUAL BASICEOriginal and photocopy of Birth Certificate authenticated by the NSO.^(ie. Driver's license, BIR ID, SSS ID, Postal ID, current Office/School ID or Valid Passport). Registrar.@1. List of Honor Graduates certified and submitted by the School# and other programming courses.> surviving husband / wife and children (sample text format to be provided).ZIssuance Date and Certificate of Veteran Status (CVS) No : _____________ Basis : ________>1. Category I (e.g. Data Encoder, Auto Mechanic, Machine ShopK Scientific and Technological Specialist (PD 997)m Please fill in the required information and submit the documents required by the CSC Regional Office. % Barangay Health Worker (PD 7883)' Barangay Nutrition Scholar (PD 1569) Degree/Highest Educational Attainment:_____________________________________________ Honors Received__________________________________XFOR PRIVATE EMPLOYEES/NON-EMPLOYED : ARE YOU INTERESTED IN WORKING IN THE GOVERNMENT?"$BARANGAY NUTRITION SCHOLAR (PD 1569) BARANGAY HEALTH WORKER (PD 7883)7 SCIENTIFIC & TECHNOLOGICAL SPECIALIST (PD 997)D issued by the Philippine Veterans Administration Office (PVAO);E issued by the National Computer Center on the following courses:uIF YES, LIST THREE (3) PREFERRED GOVERNMENT AGENCIES AND PREFERRED PLACES OF WORK/ASSIGNMENT (REGION/CITY/PROVINCE)>dismissal from the government service, and legal prosecution.&2. Transcript of Records and Diploma;@3. List of subjects taught/being taught indicating the course G number, descriptive title of subjects, and duration of teaching ofF said subject, duly certified by the Dean or any school authority.> For applicants who are teaching/have taught in College orB4. Other documents such as: Published research paper or technicalI reports for concluded research and progress reports for researchers O still in progress. The reports shall be certified true copy by authorities* to whom the originals were submitted.I scientific research project/s the applicant has participated in, theG duration, nature of participation and / or responsibilities of the* applicant in said research project/s.G1. Duly certified service record or certification of employment whichN Graduate level, include only subjects relevant to the desired eligibilityB5. Certification of Research Proficiency which indicates title ofD includes among others, a statement of the head of office/schoolI regarding his/her assessment of the applicant's research or teaching proficiency;= The requirements enumerated above shall be submitted in 5, sets each to thePD 997 Committee, DOST, FOR PROCESSOR/EVALUATOR ONLY : ACTION TAKEN I certify that I have reviewed all the documentary requirements relative to the grant of _______________________________________________________________________________# MC 11, s. 1996 (CATEGORY 1, 2)H F l0#q5  B #D%UB()+ -/1Q3Yx5{79J ; >@cc  (FKPV_zjDn  dMbP?_*+%&zG?'zG?(ffffff?)(\?MHP LaserJet 2200 Series PCL 6?dXXL.HP LaserJet 2200 Series PCL 6BJ24xe.DA:3͘a BY+dX`-:1D\R$#‚B" .k^ ع}zW}uh_3Sqhf%) d: A.C`IXlh.Yu(I O)iJK4=#""_B\a~+Bz K;dNEK)Az!>p+$" VK!#PkJN 6.5^Foʳ#YU#_f ?  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