PHOTO Government Issued PROFESSIONAL REGULATION COMMISSION I IDLicensePassport

Photo government issued professional regulation

This preview shows page 5 out of 5 pages.

42.PHOTO Government Issued PROFESSIONAL REGULATION COMMISSION-I ID/License/Passport 0751856 Signature (Sign inside the box) Date/Place of Issuan MIAGAO, ILOILO SEPTEMBER 25, 2019 Date Accomplished Right Thumbmark AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as ind CS FORM 212 (Revised 2017), Page 4 of 4 Are you related by consanguinity or affinity to the appointing or recommending authority, or to thechief of bureau or office or to the person who has immediate supervision over you in the Office, b. within the fourth degree (for Local Government Unit - Career Employees)?If YES, give details: ________________________________ If YES, give details: ________________________________ b. Have you been criminally charged before any court? If YES, give details: ________________________________ Date Filed: Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? If YES, give details: ________________________________ Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in the public or private sector? If YES, give details: ________________________________ a. Have you ever been a candidate in a national or local election held within the last year (except Barangay election)?b. Have you resigned from the government service during the three (3)-month period before the last election to promote/actively campaign for a national or local candidate?Have you acquired the status of an immigrant or permanent resident of another country? Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:a. b. c. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. I agree that any misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s against me.Government Issued ID(i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.) PLEASE INDICATE ID Number and Date of Issuance ID picture taken within the last 6 months
Image of page 5

You've reached the end of your free preview.

Want to read all 5 pages?

  • Fall '19
  • Family name, Given name, Jr.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture