rt - midas.mtrcb.gov.ph · personal data sheet (csc form 212; revised 2og5) appointrnent (kss porma...
TRANSCRIPT
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MOVIE AND TELEVISION REVIEW AND CLASSIFICATION BOARD
MASTERLIST OF FORMS
Division/Unlt: Human Resources Unit (HRU)
REVISION DATE
FORM NAME FORM NO. INITIAL ISSUE DATE I 2 3 4 5lnternal
Request for Personnel F.HRU-OO1 1?/1t16Application for Leave F.HRU{02 1?J1n6Pre-Approved Application on the Utilization of Compensatory
Time Off (Monitoring Sheet)F-HRU{03 1211t16
Overtime Service Authorization F.HRU{M 12t1t16Orive/s Trip Tickot F.HRU{O5 12t1t16Trips./ltinerary and Official Businoss Slip F-HRU{06 12J1116Client's Feedback Form F.HRU{07 12J1t16Orientation Ch€cklist F-HRU{08 1211t16Clearance from Property and Money Accountabilities F-HRU{09 1211116Personnel Action Request Form F.HRU{l0 12j1116Traininq Evaluation Form F-HRU{11 12J1116
F-H R U {12 1211116Training Effectivenegs Evaluation FormBackground lnvestiqation^/orification Form F.HRU{13 12t1116Pre-Employment Checklist (Chairperson/Executive Director ll) F-HRU{14 1?J1t16Pre-Employment Checklist (Vice Chairperson/Board Member) F-HRU{15 1?,1t16Pre-Employment Checklist (Employ6s) F-HRU{16 1211t16
ExtemdlPersonal Data Sheet (CSC Form 212; Revised 2OG5)Appointrnent (KSS Porma Blg 33; Narebisa 1998)
Records lnventory and Appraisal FormMedical Certificate for Employment (CSC Form No. 21 1;
Revised Auqust 1998)
Panunumpa nq Katungkulan
Position Description FormSworn StatBment ot Assets, Liabilitios, and Net Worth(Revis€d January 2015)
lndividual Performance Commitment and Review (IPCR)
Division Performance Commdmert and Review (DPCR)
Preparod By: Approved By
m strative Officer
SUSA
Chie,
DOLINMA, CZARINA D, AGUSTIN
Senior Adminashative Assistant ll
T II
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tl
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: rT _.]
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T{OVIE AND TELEVISION REVIEh' AND CLASSIFICATION BOARD
REQUEST FOR PERSONIiIEL
Reasons frcr Requisition:Date Needed
HigherStudies Specify:College Graduate Major in:High School GraduateVocational Course:
Wotk Ex nce
Job Requirements:Ed ucat iona I Eacko rcu nd:
Revieu/ed ByRequested By Approved By:
Date:
Divisk n Head
Date:
ChairD€.rson
Dato:
For USE ON
Rate Range EmployeeStarting Date:
F-HRU{O' 2rlt1
MOVIE AND TELEVISION REVIEYV AND CLASSIFICATION BOARDREQUEST FOR PERSONNEL
Position Uniuoffice:
Date Ne€ded Reasons for Reguisition
Job Requirements.Ed u cat ion al Backo rou nd. ) Higher Studies Specry:
) College Graduate Maior in) High School Graduate
) Vocational Course:
Work ExperienceRequested By: Reviewed By: Approved By:
Unit Head DiYision Head
Date:
Chairper&n
Date:
For employment use only:
Starting Date: Rate Range Employee
F-t{RU-{Dl flZtl15)
Date:
Posifion:- UniUOffice:
)
)
)
)
Unrt Head
Date;
Date:
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Control No
OFFICE OF THE PRESIDENT OF THE PHILIPPINES
I'TOVTT IITO TEUUSION REVIEW AND CLASSIFICATION BOARD
APPLTCATION FOR LEAVE
2. DiYision / tjnit1. Date of Rling
4. Salary3. Name
6. Employfi)ent Status5. PosiUon
1. DETAILS OF APPUCATION
a) TYPE oF LEAVE( )Vacatjon{ } Sick( ) Matemity / Patemity( )Study( )Otprs (specM
c) NO. oFWoRKING DAYS APPLIED FOR
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DAY/S
lnclusive Dates:
b) WHERE LEAVE WILL BEeoEntT
1) IN CASE OF VACATION LEAVE
) ln the country
) Abmad (specify)
d) COMMUTATION ( )Requested( )NotRequested
Signature of Applicant
2. OETAILS OF ACTION ON APPUCATION
a) CERTIFICATION OF LEAVE CREDITS
As of
VACATION SICK
HRM Assistant
TOTAT
b) RECOMMENDATION
( )Approval( ) Disapproval du6 to
Date
a) APPROVED FOR:
( )days with pay( ) days without pay( ) others (sp€city)
b) DISAPPROVED DUE TO:
( ) unreasonable purpcse( )dday of filing( )otherB (spscify)Recommendng Approval
Executive Director ll Chairnan
mtsTRUGrtoils
1. ApplEaton lor vacaton or srck lea,/e tor one ol lull day or more shall be rEde on thB form and to be accanphshed at lease rn duplEate.2. Application for vacaton leave shallbe fled in ad/ance or lrtrena,/er possible fve (5)days before gorng to $rh have.3. Apdbation lu sick lea{e mu{ be fl€d wihin ft€. (3) days qoo $e ffltor€€s rehm b ofte. Sick l€are filed in adJarf,, tr exce€atng nve (5) dars
shall be accompanied by a medical cerlifcate. ln case medical consultation uas not availed ol an affdavit should be o(ecuted by he applbant4. An enployee who is absent $/ithout approrred leave shall not be entitled to received his salary core6ponding to the p€riod of his/her uftauthorted leave ot
ab6erc€.
5. Any mbirnpresenbtion or exception in coflnection wih Ule eplbat on tu hrve siallb€ ground foI dsciplinary aclion.
F-HRU-002 (12/01/16)
(2) IN CASE OF SICK LEAVE
( )ln Hospital (spec'ty)_-( )Out Patient
Leave Parliculars:
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OFFICE OF THE PRESIDEiIT OF THE PHILIPPINES
MOVIE AND TETEVISION REVIEW A!,ID CLASSIFICAIION BOARD
PRE-APPROVED
APPLICA1ION ON THE UTILIZANON OF COMPENSATORY TIME OFF
(MoNlT0RlNG SHEET)
1. Date of Filing 2. Division / Unit
3. Name 4. Salary
5. Position 6. En'iployment Status
DETA'TS OF APPLICATION
a) No. OF I{ORKING DAYS APPLIED FOR _ DAYIS
lnclusiv€ oatos:
Signature ofApplicant
OETAILS OF ACTION ON APPLICATION
a) CERTIFICATION OF COMPENSATORY OVERTIME CREDITS
As ol
AVAILABLE LESS BALANCEL,UL ATTLIIU UT
CTO COC
Head, Human Resourc€ Management Unit
b) RECOMMENDATION
( ) AFt oval{ ) Disapproval due to
Unit / Division Head
Date
Nored by
Chief Adm inistrative Officer Chairperson
TNSTRUCTTO S
1. Application for cornp€nsatory tjme ofi chargeaue against compensatory overtirne credts shall be filed and to b€ ryroved at least turc (2)days p$or to actual utilization ol componsato{y oJ6firn6 crsdits oxcopt fu half day $ilization by Unit I oM8ion Head conc6n€d.
2. Hall day cornponsatory time ofl shall be liled and appoved on th€ day hall day crcdit is dilized.3 Any misrefiesentation or excoption in connection with the application for compensatory time otf shall be ground for disciplinary action.
F-HRU-003 (12/01/16)
Control No.:
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Approved by :
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Date
Control No
OFFICE OF THE PRESIDENT OF THE PFT1LPPINES
MOVIE AND TELEVISION REVIEW AND CLASSIFICATION BOARD
OVERT I M E SE RWC E A U I-H rlRl ZA l' ION
t/NII'DITTSTON
SAUIRY PERMONTH ,
NAME
PO,\ITIoN
WORK 10 BL PLRFORMLI)
DA1'D O1: OI.'L:RTIME ,\ERLTCE
Recommending Approval : Approved hy: Recorded hv
Division Chief t []nit Head Chairperson HRM Assistdnt
NOTE : The above blanlcs must be flled, and duly signed by the authorizing olJicer beJbre overtime serviceis rendered. otherwise. overtime service shall not be paid. A-fter approval, this form must be.fonharded to theHRf) Ass$tant.lbr proper rccordrng not laier thon he actual dqte oi overltme servtcc.
0 VE RTI M E SE RYI C E ACCOM PLI SH M E N 1' RE PORT
Date:
Workis accomplished
Date
Certified Coruect
EnployeeVerified by:
Division. Ilnit Head
HRM Endorsement:
Human Resources Mgnt. Oficer
From: To: No. of Hours
F-HRU-00 (t2t0ut6l
Approved b1t:
Chairperson
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MOVIE AND TELEVISION REYIEW AND CLASSIFICATION BOARDMTRCB Building, No. 18 Timog Avenue, Quezon City
DRIVER'S TRIP TICKET
TO BE FILLED OW BY THE OFFIC'AL AUTHORIZING THE TRAVEL :
1 . Government car to be used, Plate No
3. Places to be visited/inspected
4. Purpose
Expeded lime ol arival :
Recommended by:
Senior Administrat ye Ass,stant r/
Approved by:
Ch i e f Adm ini strat ive O ffice r
TO BE FILLED OW BY THE DRIVER :
from: _ _ toliter
A.M.
A.M. P,M
Driver's Name & Signature
NAME OF AUTHORIZED PASSENGER/S & THEIR S'GNATURE/S
1
2
3
4
6.
7.
8.(Please use another sheet if necessary)
Passengers' commenus (re: driver and driving skills)
VEHICLE INSPECTION :
Pre-trip lnspection :[ ]Car's exterior & interior is in good conditioni lSome damagels noted
lnspected by
Signature over pinted name
F-HRU{|os (r2l0U16)
Post-trip lnspection :[ ]Car's exterior & interior is in good condition when brought out[ ]Some cjamagels noted
Specify
Conforme
Drivefs signature over printed name
2. Date of Trip l
5. Expected time of depa ure:
1. Time of departure from the oifice / garage :
2. Time of anival back to office / garage :
3. SpeeCometer reading :
4. Gasoline purchased :
Speqfu : _
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, ,:lr& OFFICE OF TIIE PRDSIDENT OF TIIE PHILIPPINESOVIE AND TELEVISION REVIEW AND CLASSIFICATION BOARD
TRIPS / ITINERARY & OFFICIAL BUSINESS SLIPNo
Name
Date
Task to Perform Place to Visit / Date AddressEstimated Time
Required
lcertify that; (1) lhave reviewed the foregoing itinerary, (2) thetasks and trips are necessary to the service, (3) the estimatedtime to perform the above-stated tasks are reasonable.
Prepared by
lmmediate SupervisorPinted Name Over Signature
Employee Name and Position Over Signature
Destination AS STATED ABOVE
Mode of Trsportation : ( ) MTRCB Service Car ( ) Public Vehicle
Recommending Approval:
( ) Personal/Private Vehicle ( )Other
Approval:
Division Chief / Unit Head Executive Director ll
(To be filled-up by the guad-on4uty)
Time of Departure :
Remarks :
Time of Arriyal
Guard on Duty
Nole: This lorm shall be flled{p in duplicato by lhe employe ard mlst be 4pmv€d by tle Ex€culivB Dileclor 006 x,e6k at|ed of schedule. The omployee shall submit tttisfom lo HRM Unit for bip scl|edule, give h€ duly 4proved brm to tle guad{.Fdul, befo(e leaing tle ofice. An e,nployee who leav€s tl€ offce during otrce hours ivittrcdlhis duly approv€d fom is subioci to corrlspoding sday or loave cr€dit doductoi dd shall nol bo consirssd oi oficid b0sin6s6.
( ln Two (2) Coplos )
M1'RCB
F-HRU-m6 (12./1/161
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fiaMTRCB
IOYaB & TEr-ESISION rBvlAlr & Cr-isslflf,lfTtotia E() ,rltl, E!- r\r! ll r-..^rr Qc
cld! l.-,o''-* r'{,E
Date: Time:
Nme oT,VTRCB Strticc office :Name ofActioa Officcr
Clie t's Name:Cdtlct NumbecPosition /Of6cc Name & .\rlrlrcr
Pulpose of Visit:
Part I : Clieot's lhtisfection Rating
How do vou rate our scrvice?
t outst nding I I z- u"a.,"-.at'g+ Very Sotishctort
3- satist1ctl)r}
Part II : Clicnt's Fccdb.ck
1: Plcrsc Chcc[ il vou arc proiding.r complirrcnL
erge.tiar ot co.rplaina:
f-l cn-pu*',, l--l s,pe$d-, Cornf'ldnt
z tJxcts or Dctxils of drc incident
3. Recornnrndation/ SugSesdon/ Dcsircd Actiori
fro,rn our Of6ce;
*Ple.se put thb fonD;n t}le dmp boi you 'nry
dso scfjd
us your feedb.ck through en'ril addrcss
F-IlRU4o7 (12/01/76)
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MOVIE AND TELEVISION REVIEW AND CLASSIFICATION BOARD
ORTENTATION CHECKLIST
Employee
Position Unit
Date
IHSTRIJCTIONS:
Upon repo{ting for Yvork by the new empb}€e, cr}eck eacfi item afrer compbtbn of orientation. Thi6 Orientaticn Checktistsha{ be retumed to lhe Human Resource lianagement Unit for filing in the 201 File.
SECNON I - HUTAN RESOURCE TANAGETENT UNIT
1. The MTRCB history, developmentorganization, management, services,type of industry.
2. MTRCB policies, what to expect of theBoard.
3. Terms of employment generaldisciplinary rules and procedures.
4 The concem for absenteeism andtardiness.
5. Employee activities, heath care, sbkleave plan, vacation leave plan,matemity. vacation leave plan, socialsecurity/philhealth, pag-abE, promotircn.job evaluation system, and loan plans.
6. Wage policies:a) Board ratesb) Wage progression schedule; itspurposes, advantages; merit rating andconesponding merit increase.c) Regular time; overtime; holidayand Sunday premiumsd) Time and method of payment ofwagese) Tamekeeping
7. lmportance of bulletin board.8. lnlroduce him to his superiors.
S
1 . Head's personal welcome.2 Head's name and position.3. Empbyee's nickname.4. Explain the Unif s organizatim.5. Explain the Board's interesl in his r /ork
and welfare.6. Explain his job, its importance to
himself, his fellow employees, hissuperior, and his Company, \i/tlom heis to report b.
7 Explains details of employment,performance evaluation system.
8. Explain work schedules (\Norkweek;break period; meal periods).
9. What the Board expects of him.10. What he can expect of the Board and
his supedor.
sEcnoN il - QUALIW ilANAGETENT SYSTET (TO BE DTSCUSSED BY THE OrS)
'1. Quality policy2. Ouality arv:areness3. Quality System Documentation
4. Coneclive and Opporhrnitylmprovement Procedure
for
HRU Staff Unit Head QMR Employee
F+tRU4oa (lz1lr6)
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file @fiitt of tlc fr'rilam of t e ptalimirctMOVTE & TELEVISION REVIEW & CLASSIFICATION BOARDIITIiCB Building. No- l8 Timr4 Avenue, Que.zol City
Tei, No. (02) 37G738O Fax r\o, (O2) 376-7379 Email: admi*
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Movie and Television Review and Classification BoardPERSONNEL ACTION REOUEST FORM
Date Hire: Effectrue Oate. Dste Submitted.Name.
Address.
Telephone No.. Rate of Pay: P lD Noi
E Unit Transfer E Menl lncrease tl PromotidrDemotion B Annual Review D Other
Date ol Birth: Marital Stratus: Sex.Exemptron
E Male E Female
New Department: New Job Tifle:
Old Rate of Pay: P_ per _ New Rate of Pay: P per _ Effectiviry Date:
Effectivity Date:New Benefit:
New Name: New Phone No.
Ne-w Address' Marital Status:
O Termination D Retirement D OtherE Resignation
Explanation;
Leave Pay: Severance Pay: Last Day Wcrked:
E With ReservationWouk You Rehire?
EYes nNo
Unil Head:
Dft'rsron Head:
Chie, Administrative Offi cer:
Date:
Date.
Date:
OatelChairperson:
F-HRU{10 {12/'rrr6)
--l
PERSONAL
TERI'INATION
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MOVIEAi{D TELEVISION REWEW AND CLASSIFICATION BOARDTruINING EVALI,IATION FOKII
LECTURER,,SPEAKER: DA IE:INSTRUCTIONIi: Please chcrk the column which bcst de$ribcs yurr evatuation of the program. your
adt!n wiil hcl ideltifv the art'as lbr r. llank
COMMENTS AII{D SUGGESTIONS:l- What did 1ou like b;est nbout the semin3r?
2. What did you like least atx.ut the seminar?
.3- \ltat should bc done to improve the seminarl
4. Whal othsr topics should hat-e bcen inclucied in the seminar?
5- Othercommentirulgesdons
RATlir,iCCRITERIA
Erc-ellrnt Yery Good Cood Fair Foor
I SEIVIINAR OBJECTN'EClear Slattmcnt
AttainIn{.nt
2. SEI\,TINAR CONTENTRelevance Usefirlness
Coverage
Oqanizarion
Tinrc allotment
]. SFMt:VAR MATERIALSReading materials
Visuat aids:
i
-l LEC'TURES
Subject kmwledgs
Tcaching cflectivr'ness
A'rrlience iriemctioir
5. SEMI^-AR SCHEDULEDuration
Frtquency o{sessions
6. FACII-ITII:-S AND FOODRffrm
Air condhioning
l'rxxl
7. OVERALL RATINC
F-HRU-0i1(t?JlltS)
PR0GRAitl,'COtiRSE:
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MOVIE AND TELEVISION REVTEW AND CLASSIFICATION BOARDTRAINING EFFECTTVENESS EVALUATION FORM
Ratrngs 3 - Employee demonstratG exc€llent ski[s2 - E t9q/ee demonstrrates very good skilb.1 - E.rployee dernonstrates sdisfaclory skdls0 - Ernpbyee demon3ffies poo. skills.
EVALUATED BY: DATE EVALUATED:
FORM CODING
NAME DATE/VENUE:
TRAINING
SPEAKER/COMPANYOBJECTIVE'S
TARGETSKILUS
RANNG(Pr€-
Training)
RATING(Po6t
Training
REMARKS'ACTION PLAN
ABC COMPANYTRAINING EFFECTIYENESS EVALUATION FORM
NAME
SPEAKERICOMPANYOBJECTIVE'S
TARGETSKILUS
Ratings: 3 - Enployee domonstrat€ .xcelbnt skils2 - Employee dernonst ale3 y€ry good skilb.1 - Employee demonstrate satistudory stilb.0 - Employ€e de.nonsirates poor skilb-
RANNG(Pra-
Training)
RATING(Post
Training
REiIARKS'ACTION PLAN
DATE EVALUATED:EVALUATED BY:
DATE/VENUE:
TRAINING
F-HRU-012 (12ll/r6)
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Background Check:
CANDIDATE NAME:
TNTERVIEWEE :
Company Name
Date of Emplol.rnent
Position(s) Held
Salary'History
Reason for [raving
MOVIE AND TET.EVISION REVIEW AND CIASSIFrcANO EOARDPRE.EMPLOYMENT BACKGROUND INVESTIGATION FORM
: From : To:
Explain the reason your calUvisit and veri! the above information with the supervisor/staff(including the reason for leaving)
I . Please describe the type of work for which tirc candidate was responsible.
2. How would you described the applicant's rclationship with coworkers. subordinates (ifapplicable),and wil.h superv isors?
3. Did the candidate have a positive or negative work attitude? Please elaborate.
4. How would you describe the quantity and quality of output generated by the former employee?
5 . What were hiv?rer strenglhs on the job?
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6. What were hiJher weaknesses on the job?
7. What is your overall assessment ofthe candidate?
8. Would you recornmend him/her for this position? Why or why not?
9. Would this individual be eligible for rchire? Why and why not?
Other comments?
Interviewer's Signature:
Date :Irterviewee's Signature:
Dal€
r-HRU-or3 (t2ll/16)
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PRE,EMPLOYMENT C H E C K L I S T(Chairperson/Executive Director II)
MANDATORY MINIMUM SUPPORTING DOCUMENTSFORTHE FIRST SALARYOF CFIAIRMAN And EXECUTTVE
DIRECTOR IIPut { or X if the item has been complied.
Appointment duly approved by the appointing authority
Oath of Office
Personnel Data Sheet
Resume or bio-data with 2 recent passport-sized pictures
Statement of Assets and Liabilities (4 copies with original signatures of the
appointees and spouses)
Certificate of Assumption
Taxpayer Record Update (Revised BIR Form 1902)
GSIS Membership Form (2 copies)
HDMF Membership Form (2 copies)
PHIC Membership Form (2 copies)
NOTE:
Please submit the above documents upon completion to theHuman Resource Management Unit (HRU Unit) for processing.The release of your first salary will depend on your speedysubmission of the same.
F-HRU-{'14 (r2ll/16)
HRM Unit
Thank You!
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(Vice Chairperson/Board Member)
Appointment duly approved by the appointing authority
Oath of Office
Personnel Data Sheet
Resume or bio-data with 2 recent passport-sized pictures
Statement of Assets and Liabilities (4 copies with original signatures of the
appointees and spouses)
Certificate of Assumption
NOTE:
Please submit the above documents upon completion to theHuman Resource Management Unit (IIRM Unitl for processing.The release of your first salary will depend on your speedysubmission of the same.
Thank You!
HRIVI Unit
F-HRU 0t5 (12lt/16)
PRE.EMPLOYMENT C H E C K L I S T
MANDATORY MINIMUM SUPPORTING DOCUMENTSFOR THE FIRST SALARY OF CHAIRMAN and EXECUTTVE
DIRECTOR IIPut { or X if the item has been complied.
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PRE-EMPLOYMENTGHECK LIST(Employees)
MANDATORY MINIMUM SUPPORTING DOCUMENTSFORTHE APPOINTMENT AND FIRST SALARY OF NEW EMPLOYEE/S
Put ! orX if the item has been complied.Appointment duly approved by the appointing authority
(to be prepared by the HRM Unit)
Oath of Office (to be prepared by the HRM Unit)
Personnel Data Sheet (3 copies)
Resume or bicdata with 3 recent passport-sized pictures
Swom Statement of Assets, Liabilities and Networth (3 copies)
Certiflcate of Assumption (to be prepared by the HRM Unit)
Taxpayer Record Update (Revised BIR Forms 1902)
GSIS Membership Form (2 copies)
HDMF Membership Form (2 copies)
PHIC Membership Form (2 copies)
NBI Clearance
Medical Certificate issued by a Govemment Physician attesting his/her fihess to work
Authenticated Copy of Certificate of Eligibility
Authenticated Copy of Diploma and Transcript of Records by the issuing School
Daily Time Record as the Date of Appointment (to be prepared by the HRM Unit)
NOTE:
Please submit the above documents upon completion to the Hunaa RelourceManagement Uait [HRil Uaitf for processing. The release of your Iirst salary willdepend on your speedy submission of the same.
Thank You!
F-HRU{r16 ('.t2t11161
HRDI Unit
-
PERSONAL DATA SHEET
bn ,a,E'd4
212
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ItlCLUSrt/E OAIES
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FIU'I To
i{-[BER OF
Ho'RSPGTTrc I MIURE OF WORK
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COtrIJC]EU SPOEORED BY(wbh tr)
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33. 31 35 ASSMAIIOISGANIZATIOIraol.lc{frc flsrrElros, REcGuItot
u*h h ro
(Cortlnuo on lDprEto sh6et ll necertary)
CS FORti,t 212 (&riscd 405), Pee 3 o{1
W". OTHERINFORMATION6l
VI. VOLUNTARY WORK OR INVOLVEMENI ,N CIVIC / NON.GOVERNMENI / PEOPLE I VOLUNTARY ORGANITAT'AN$
TRAINING PROCRAMS from the most rccent
-
Are )ou reHed by ctrrsaEuhity or dtrdty b aly d tn lo{owing :
a- WiE*l &e Utd degrce (tor Ndind Go}€'illEd EnTblees):
+poiufU afrory, reconnrrdnng aluFlfly, d*d d ffice,UrB/depf,trE tt r p€tsm r*ohas irnEdde c.pervi$n oct yol h tle Ofte, Bueal or Depdfist rtlefe y ril beapcir*aZ
b. Wfih [Et rtr degrEe (br tocd Golremn€fit EflThyees]:appoitE afidfy or rcsmnnOiU amrny due Yu, ril be 4pried?
CYES f]NOlf YES, give de&fls:
37 a. HaYe,oo e!,er been bmdy dt ged?
b. Hae FU eler be€fl grfly d aty d]I*liffiiE ftrse?
EYES ENO
ll YES, g B d€6:
3s. tlave !u, eErbe€n cdrui:tsd of ary(,ilE ff vilEin datyla, decrBe, oldiEEoaIeguldilt by ary cutrt r thrC?
trYES DNOllYES, gire deds:
39. Hac you eryer be€n sepr*d fun be s€ryice h ary d 0E hloriB rEdes: ]et*lndin,eli€fiEnt dwed fsn the rols, disfiissd, Erllidin, end of hrnr fiidnd contsad, AWOI- orphEd ott h he Fffc s fivde sedi?
DYES trI{O
ll YES, $l" deids:
o. Hae )ou erer been a candid* h a ndi d r bcd eledin (erced BrJlgay eledilo)? DYES O NOlf YES, gtue defib:
11 Pur$ [ b: (a) Indigenous Peophb Ad (RA 8371 ); (b) ttiagna Cata ftr Disdled Persls (RA722); ad (c) Solo Paab wdEe Ad of Zm (RA 8972), *6e aEffi tle h[ortug E ns:
a Are ,ou a fiEr$er oI ary hdlJernts g]oup? EYES tr ltIOlf YES, Fce specilfIIYES Otttolf YES, *6e sped&f}YES trtioll YES, *6e spccifi
b. Are ,ut difrrErfiy dled?
c. AIB yql a solo paellt?
MI,E ADORESS IEf [O
13. I dedde [de. odr hd fis PeGond Dda SH has been m.rpldEd by rE, ad b a ttE, conect drlcilnphe gabflr({F sEt b [E p(wi*rc d perlhed hB' n*s al(l ]esthlims ol he ReFtac of hePltriEs
I &o afub tE aglnsy H / afisized tEpr€sentdiE b w[ / vd* lhe caftnb sbtsd h€reh. I tustt\d 0iB hhnndioo $d ftndr cofidenttd.
lD dull t*.i wilhinthe lBl 6 ntonth!3.5 crn. X 4.5 crn(pc.pod Cz6)
Cdnqt sEn€rded6 Errr copy aa piirE
PHOTO
SEMILnE (Sign rnside the box)
I
ISSUED 0 (rmrdd4,yyr) DAlt ACaorPUSr€D RIGHT T}{,I[ITAR'(
CS FORI 2l2 (Re!/is€d 2005), Pagelof4
42 REFTRET{CES
trYES DNOllYES,$rcde*:
trYES trl{OIYES,$Yed*:
COt'f,'{ITY IAX CERTFICA1E NO,
ISS.ED AT
-
KSS PORMA BLG. 33(Narebba, 1998)
Office of the president
MOVIE AND TELEVISION REVIEW AND CLASSIFICATION BOARDMTRCB Building, No. 18 Timog Avenue, euezon City
Ginoong/Gng./Bb.:Mt,/Ntrs./Ms.
Kayo ay nahirang na na\ ot are hoeby tppointed as
may katayuanguith a
sa MOVIE & TETEVISION REVIEW &( Status ) at the ( Ateflcy )
CLASSIFICATION BOARD (MTRCB) sa pasahod natlith a compensation rate of
(P
Ito ay magkakabisa sa petsa ng pagganap n9 tungkulin subali't di aaga sa petsa n9'I1E efectivit\ dote ol this aryifltutatt sl]rll be tlv date of achul ossumption W the aryintee bat not e\rlier tlqt the daE
pagpirma ng puno ng tanggapan o appinting authority.date of kswn& of the apryintnent which is the date of the sig],lg of the aryinti ga thority
Ang appintmenf na ito ayThis aypointment is
bilang kapalit ni( Original, Promotion, etc . ) orce
natttho
at ayon sa( Transferred, Retired, etc. ) and in accordance with
Plantilya Aytem Blg. PahinaPagePlafiilla ltem No
Sumasainyo,Very tn y yours,
Puno ng TanggapanHcad oJ Agenty
Petsa ng PagpirmaDate of Srgning
Awtorisadong OpisyalKomisyon n9 Serbisyo Sibil
A u I hori:ed Ofi dal,/Ciuil Sentirc Commission
) piso bawat taon.pesos pet aflnum
-
SERTIPIKASYON
Ito ay pagpapatunay na lahat ng dapat gawin at mga kailangang dokumentopara sa appointment na ito ay ayon sa CSC MC No. 4Q s' 1998 ay nasunod na,narebisa ko at napatunayang nasa ayos.
This is to ceftify that all rquirements and suppofting Fpers pursuant to MC No. 44 s.
1998 have ben complid with, reviewd, and found to be in order.
pub/ishdwa5
(on)
noongat)
Ang posisyon ay nalathala sa(The @otton
SUSAN L. BANDOLIN
Ch iet Admin istrative Off icer
Ito ay pagpapatunay na ang nahirang ay nagdaan sa pagsusulit ng Perconnel
Selection Board at kwalipikado.
This is to certiy that the appoint@ has ben scrend and found qualifid by thePtomotion/Petsnnel Selection Botd.
S E RTI PI KASYO N
ATTY. ANN MARIE L. NEMENZOChairperson, Personnel Selection Board
MGA NOTASYON
ANUMANG BURA O PAGBABAGO SA AKSYONG G]NAWA NG KOMISYONNG SERBISYO SIB]L AY MAGPAPAWALANG BISA SA PAGHIRANG NA ITOMALIBAN KUNG ANG PAGBABAGO AY NASULAT NA KINUMPIRMA NGKOMISYON.
Petsa ng paglabas sa KSS/Komisyon
Mga Pagbibigyan Ng Kopya
OrihinalPangalawang Kopya
Pangatlong Kopya
c:\csc-appoir(ment form
hrm unit
-
IZATIONALNATIONAL ARCHIVES OT THE PHILIPPINES
Pambansang Slnupan n9 Plliplnas
RECOROS INVENTORY ANO APPRAISAI OAT€
RETEI|TIOiI PERIOORECORDS 3ERIE3 TITLE I OE6CRIPYETi PERIOO COVEREO LOCATION OFRECORDS
FREQUENCY OF
UAEOUPLICATIOI{
TIHE VALUE UTIITY VALUE
Tot!lotsPostTtotl PRovtStoil
TIME V&L'E
UNI'TY VAIUE:
ASSISIED BYr APPROVED BYrPREPAREO BYI
NsmerndF sltlon - NAP Recoda l"Ia'iagbmenl Antlyst ch€l or $e ov8,on/oepertrnent
AGENCY IELEPHONE NO.
AOORESS PERSOI{.IN4HARgE OF FILES
-
CSC Form No. 211 (Revised August 1 998)
iIIIIIG[1 GTNTITIGITTfor Employment
INSTRUCTIONS:1. This medical ceftificate should be accomplished by a govemment physician? Attach this certificate to oiginal appointments and reinstatements.
FOR THE PROPOSED APPOINTEE
N A M E ( Last, First, Middle, orif manied woman, Maiden Name )
ADDRESS
AGE SEX CIVIL STATUS
AGENCY / ADDRESS
PROPOSED POSITION
Pre-Employment Medical - Physical Tests
1. Blood Test2. Urinalysis3. Chestx-ray
4. Drug Test5. Neuro-Psychiatric Exam
(if necessary)
N O T E : All results of examinations must be attached to this form.FOR THE PHYSICIAN
I hereby certi$ that I have personally examined the
abovenamed individual and found him/her to be
physicallyand medically F lT / UN F lTFOR EMPLOYMENT,
AFFIX
Documentary
Stamp Here
Other lnformation About the Proposed Appointee
HEIGHT (bare feet) WEIGHT ( stripped) BLOOD (tyw)
Signature over printed name of physician Certilicate Number
Official Designation Agency
-
Ako SI ng
na
hinirang sa katungkulan bilang ay taimtim nananunumpa na tutuparin ko nang buong husay at katapatan, sa abot ng aking
kakayahan, ang mga tungkulin ng aking kasalukuyang katungkulan at ng mga
iba pang gagampanan ko sa ilalim ng Republika ng pilipinas; na akingitataguyod at ipagtatanggol ang Saligang-Batas ng Pilipinas; na tunay na
mananalig at tatalima ako rito, at susundin ko ang mga batas, mga kautusang
legal at mga dekretong pinaiiral ng mga sadyang itinakdang maykapangyarihan
ng Republika ng Pilipinas; at kusa kong babalikatin ang pananagutang ito, nang
walang ano mang pasubali o hangaring umiwas.
Kasihan nawa ako ng Diyos.
Nilagdaan at pinanumpaan sa harap ko ngayong ika-_ ngA.D, sa Quezon City, Pilipinas.
PANI]NIIMPA NG I{A1I'I]NGIruLAN
Government Issued ID:ID No. :Date Issued :
-
POSITION DESCRIPTION FORM
'10 STATEMENT OF ACTUAL DUTIES AND RESPONSIBILITIES. List them belowaccording to their importance. lf more space is needed, please attach additionalsheets.
Percent OfWorking Time DUTIES AND RESPONSIBILITIES
( PLEASE SEE ATTACHED SHEET )
1, NAME OF EMPLOYEE ( Do Not Fiil Nos.5-g )OCCUPATIONAL GROUPTITLE
5
2. OFFICE/PRIMARY UNITa. Divisionb. Work Station
6. ocPcCLASSIFICATION
(wAPCO)
3. OFFICIAL DESIGNATION OF POSITION 7 WORKING OR PROPOSEDTITLE
4. COMPENSATION
a. Actual Salaryb. Authorized Salaryc. Other
8. PRESENTAPPROPRIATION ACT
a. ltemb. Fund
9. PREVIOUSAPPROPRIATION ACT
a. ltemb. Fund
-
1',t. POSITION TITLESUPERVISOR
OF IMMEDIATE 12. POSITION TITLE OF NEXT HIGHERSUPERVISOR
13. NAMES, TITLES AND ITEM NOS. OF THOSE YOU DIRECTLY SUPERVISE (lf more than 7,list only by their item nos. and titles)
14. MACHINES, EQUIPMENT TOOLS , ETC. USED REGULARLY IN PERFORMANCE OFWORK
15. CONTACTS (Please check)Occasional Frequent
General PublicOther AgenciesSupervisorsSubordinatesManagementOthers (specify)
16. vloRKtNG coNDtTtoNsGood
NormalPoorField WorkField TripsHazardousOthers (specify)
17a. I CERTIFY that the above answers are accurate and complete.
Date Signature of Employee17b. Describe briefly the general function of the Unit or Section,
18. Oescribe briefly the general function of the position.
19a. lndicate the required qualifications by educational attainment and years and kind ofexperience considered in filling a vacancy for this position. (Keep the position in mind rather thanthe qualifications of the present incumbent-
EDUCATION :EXPERIENCE & TRAINING :
19b. Licenses or certificate required to do this wort, if any.
20. I HEREBY CERTIFY that the above answers are accurate and complete.
Date Signature and title ofimmediate supe&isor
21. APPROVED.
Date Head of Agency
-
Rcviscd a3 orJanuary 2015Per CSC Rcsolution No. lSOOOaaPmmulgatcd on Janua.y 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTHAs of
(Requfed bv R.A. 6713)
Not r Husbatd ^nd
@W uho $e both wblic ofrcials drd enplagees ma! frle the requiftd std,emerts johdg or sep@detvQ Joint Rkng O Separate Filing O Not Applicable
DECLARANT:
ADDRESS:
SPOUSE:
(Familv Name)POSITIO!g:
AGENCY/OI'FICE:
OFTICE ADDRE€Ig:
POSITION:
AGE CY/OFFICE:OTrICE ADDREAS:
(M.1.)
{Family Nsme) (Ftrst Nsme) (M.r.)
UNMARRIED CHILDREN BELC'W EIGHTEEN (T8I YEARS OF AGE LryING II{ DECLARANT'S HOUSEHOLD
DATE OF BIRTH AGE
ASSETS LIABILITIES AT{D NETWORTH(lncluding those of the spouse and. unmarried children belou.t eigfueen (18)
years of age liuing in declarant's household)
1. ASSTETSa. Real Propertleaa
DESC.RIPTION
b. Personal noee*tes*
ASSESSED
VALI'E
CURREITT FAIR
UARIIET VAII'E
ACQI'ISITIO}TAIND
Ie.r. qidential,@ltrerci.r. indlsbi.UagricultuEl and mied
u&)
EXACT
I,OCATIOI{
|,4! found in t}te Tax De.laration ofE at Pt $e
-
2. LIABILITIES*
NATURE
TOTAL LIABILITIESI:
IYET wonTH : Total Arsett l€'3 Totd Lteb ttle. =* Additional sheet/ s may be used, if necessary.
BUS INTERESTS AND FINANCIAL COT{NECTIONS
(of Dectdrant / Declotdftt's spotEe/ Uftmarrietl Childrcn Belou Eighteei (1A) Aears of Age Livilg in Declarant's Hol6ehod)
E! I/ We do not haue anA business interest or financial connedion.
OUTSTANDING BAIAI{CENAUE OT CREDITORS
NAf E OF EI{TITY/ BUSINq9SENTERPnISE
BI'SINESS ADDRESS NATURE OT BI'SINES,gIIOTEREST &/OR FII{ANCIAI
coNl{BcTrot{
DATE OF ACqI'ISITION OFINTEREST ON COIIITECTION
RELATTVES IT{ THE GOVERNMENT SERVICE
lwirhi!.lhe Fourth Degree of CotBonguinitg or Affvtity. hEhtd. dlso Bik1s, Balae drd lnso)
O I/ We do not lcrLou of any relatiue/ s in the gouernment seruice)
NAME OF RELATIVE RELATIOI{SHIP POSITION NAI'E OT AGENCY/OFFICE AXD ADDRESS
I hereby certiry that these are true and correct statements of my assets, liabilities, net worth,business interests and financial connections, including those of my spouse and unmaried children below
eighteen (18) years of age living in my household. and that to the best of my knowledge, the above-enumerated are names of my relatives in the government within the fourth civil degree of consanguinilr or
amnity.
I hereby authorize tlre Ombudsman or his/her duly authorize d represeltative to obtain andsecure from all appropriate government agencies, includirtg the Elureau of Internal Revenue suchdocumeots tJrat may show my assets, liabilities, net worth, business interests and financial connections,
to include those of my spouse and unmarried children below 18 years of age living with me in myhousehold covering previous years to include the year I first assumed office in govemment.
Date
(Signarwe of Co- Declarant / Spou.se )
Government Issued IDID No.:Date lssued:
9UB{ICRIBED AI|D SWORN to before me ttris
-
day ofme the above-stated govemment iss.red identification card.
, affiant exhibiting to
( P er son Administering O ath)
(sig afi,re of Dedrrrafti)
Ci,ovemment Issued ID:lD No.:Date Issued:
-
i/tovlE AND IttEvtstolt iEvltw aND cLASSIFtCATtoN BoAIDII{OIVIDUAT }IRFORMANCE COMMITMTMI AND REVIEW
l,
-,
oflhe ..onmit io deliver and agreeto be rated on the.ttainmenl ofthe followinStargels in ac.ordancewirh the lndLated me.surcr for theperiod--to-_.
(T aActual A..ompli$menls
E T
lntnmediate Supe.visor
-
Comm.DR .nd RelomnEndarirtrs lor O.!.lopm.nt Purpo{s
finalAvcr.E Rating
Asr.ss€d by: I ceriily lhnl I dicussed my asesme.t of lhe Ftcrformance wirh rh€ lmployr.
AsencLte8€ndr Q" qu.ntiry/Elli.i.ncy
natl.8Sc.l. r5 - Out3randh& 4-V.ry S.iElactoryj
E- Eff.divenesrQlr3lity
3 - sati5fa.toryi 2 - Unetistaclory; 1" Poor
-
MO!'I!] ANI) I'}:I,tJVISIoN Rt]VIIJW ANI) CI"{SSIITICA'I'ION ROARDT)IVISIoN PI.JRI]oITMAN(:I.: (JoMMI'LMIiN'I' ANI) RIiVII.]W
RATING SCALIi5 - Outstanding
4 - VEy Sa.i6foctory3 - Sati sfactory
2 - Un s.tisf.c-tory
I - Poor
bv,
I lced of fucncy I)alc\ision Chicf/tlnn Head [)atc
folkrwing targtis in accordance wirh the indicatcd measures foi the p6iodcommit to deliver and aglce to bc r.ted on rhc aaaiflment ofthe
2015.
I, __- , Unit Ileed ofthe_
RA'I'TNG Rem.trksMFO/PA-P Allotted
Ilu
Indi\iduals Actual Accomplishments
t1. 't'
rII
IIII
Success Indic{ors
rI.rpe.6 + Me.sur€s) o
ll-tI
-
'I otal ()verau Rating
Final
Rating bT :
IIcad of
bv,
DAtc D{te
IITTrIIIrlrrIITIIIII
l,egmd: Q- Quaotity/Emcicncy E- F:ffec:tivcness/Qurlity 'r- Timcless A- Aver T - TimelinessAdi(ti!al Ratine