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 5

lnternal

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 12t1t16

Orive/s Trip Tickot F.HRU{O5 12t1t16

Trips./ltinerary and Official Businoss Slip F-HRU{06 12J1116

Client's Feedback Form F.HRU{07 12J1t16

Orientation Ch€cklist F-HRU{08 1211t16

Clearance from Property and Money Accountabilities F-HRU{09 1211116

Personnel Action Request Form F.HRU{l0 12j1116

Traininq Evaluation Form F-HRU{11 12J1116

F-H R U {12 1211116Training Effectivenegs Evaluation Form

Background lnvestiqation^/orification Form F.HRU{13 12t1116

Pre-Employment Checklist (Chairperson/Executive Director ll) F-HRU{14 1?J1t16

Pre-Employment Checklist (Vice Chairperson/Board Member) F-HRU{15 1?,1t16

Pre-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

-I

tl

_____

: rT _.]

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 Experience

Requested 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:

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

-

DAY/S

lnclusive Dates:

b) WHERE LEAVE WILL BE eoEntT

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 applbant

4. 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:

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 BALANCE

L,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.:

-

Approved by :

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 service

is rendered. otherwise. overtime service shall not be paid. A-fter approval, this form must be.fonharded to the

HRf) 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

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: _ _ to

liter

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 condition

i 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 : _

, ,:lr& OFFICE OF TIIE PRDSIDENT OF TIIE PHILIPPINES

OVIE 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 tttis

fom 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 ivittrcd

lhis 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

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 Numbec

Position /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)

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, his

superior, 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:areness

3. Quality System Documentation

4. Coneclive and Opporhrnitylmprovement Procedure

for

HRU Staff Unit Head QMR Employee

F+tRU4oa (lz1lr6)

file @fiitt of tlc fr'rilam of t e ptalimirctMOVTE & TELEVISION REVIEW & CLASSIFICATION BOARD

IITIiCB Building. No- l8 Timr4 Avenue, Que.zol CityTei, No. (02) 37G738O Fax r\o, (O2) 376-7379 Email: admi*<qmtrcb.gor,.ph

foTTRCB

CEf,TIFICATE CF TLEARAXCE

PLIRPOSE.

This is to certily that

, is cleared of all money and property

accountabilities with the Movie and Television Review and Classification Board

{MTRCB) as of

in Quezon City

Senior Administrative Assistant ll Administrative Officer V

Administrative afficer V Accountant lll

Chief Administrative Officer

F-HRU{09 { t2i trt6)

lssued this _ day of _,

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 Reservation

Wouk 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

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 SCHEDULE

Duration

Frtquency o{sessions

6. FACII-ITII:-S AND FOOD

Rffrm

Air condhioning

l'rxxl

7. OVERALL RATINC

F-HRU-0i1(t?JlltS)

PR0GRAitl,'COtiRSE:

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)

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 EOARD

PRE.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?

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)

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!

(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.

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

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(Condtiuo on soparrlr srroo I ll oGcorsary)

CS FoRII 2t 2 {R.Nisd 2qE}, Fdge 2 oa l

IV. C'VIL SERVICE ELIG'BILITY

IIIIIII

II

V. WORK EXPERIENCE (lnclude p veta employment. S'f/rt frcn yout cufientwotk)

@E IIIIIIIIrIIIIIIIIIIIIIITIIIIIIITrIIIIIIIIIIIITITIIIIIIIIrIITIIIIrIITrrrIIIII

ItlCLUSrt/E OAIES

(iltt$,yrry)M E I ATINESS G MGAMzIIX}I

(I*lh r.)31.

FIU'I To

i{-[BER OF

Ho'RSPGTTrc I MIURE OF WORK

I I I

tt

I

tt3hOOt

"t

on

Fll.n To

[{cr-(sll/E 0 rEs GATImrf,E(rnfityfry)rrnE GS€I0{ART0fERETEEI$,08(S e'SrmTcclnsEs

(Ylbhr9M,ISERG

Hd-RS

COtrIJC]EU SPOEORED BY

(wbh tr)

tt tt

lt lt

lt tt

I tt

ll

tl

tt tt

tl lt

ll ll

ll ll

tt

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tho€t,',

SPECI,AI SXILLS / HMES:

on

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*o

has irnEdde c.pervi$n oct yol h tle Ofte, Bueal or Depdfist rtlefe y ril be

apcir*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- or

phEd 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 NO

lf YES, gtue defib:

11 Pur$ [ b: (a) Indigenous Peophb Ad (RA 8371 ); (b) ttiagna Cata ftr Disdled Persls (RA

722); 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 ltIO

lf YES, Fce specilf

IIYES Ottto

lf 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 tust

t\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 DNO

llYES,$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 Opisyal

Komisyon n9 Serbisyo SibilA 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 dokumento

para 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 the

Ptomotion/Petsnnel Selection Botd.

S E RTI PI KASYO N

ATTY. ANN MARIE L. NEMENZO

Chairperson, Personnel Selection Board

MGA NOTASYON

ANUMANG BURA O PAGBABAGO SA AKSYONG G]NAWA NG KOMISYON

NG SERBISYO SIB]L AY MAGPAPAWALANG BISA SA PAGHIRANG NA ITO

MALIBAN KUNG ANG PAGBABAGO AY NASULAT NA KINUMPIRMA NG

KOMISYON.

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 COVEREOLOCATION OF

RECORDS

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 Test

2. Urinalysis

3. Chestx-ray

4. Drug Test

5. 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 na

nanunumpa 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 aking

itataguyod 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 UNIT

a. Division

b. Work Station

6. ocPcCLASSIFICATION

(wAPCO)

3. OFFICIAL DESIGNATION OF POSITION 7 WORKING OR PROPOSEDTITLE

4. COMPENSATION

a. Actual Salary

b. Authorized Salary

c. 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 FrequentGeneral 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 2015

Per CSC Rcsolution No. lSOOOaa

Pmmulgatcd 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. ASSTETS

a. 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<(yl

YEAR ODE

ACQrrIarnot(

coaT

Subtotal:

DESCRIPTION

Subtdal :

YEAR ACQI'IRED ACQI'EIIION

cosT/A-fou r

' Additional sheet/ s mag be used, if necessary.

Page I oJ

TOIIAL AIFEIS (a+bl:

(First Naoe)

NAME

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,g

IIOTEREST &/OR FII{ANCIAIcoNl{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 and

secure from all appropriate government agencies, includirtg the Elureau of Internal Revenue such

documeots 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 my

household 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 ROARD

T)IVISIoN PI.JRI]oITMAN(:I.: (JoMMI'LMIiN'I' ANI) RIiVII.]W

RATING SCALIi5 - Outstanding

4 - VEy Sa.i6foctory

3 - 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-t

I

'I otal ()verau Rating

Final

Rating bT :

IIcad of

bv,

DAtc D{te

IITTrIIIrlrrIITI

IIIIl,egmd: Q- Quaotity/Emcicncy E- F:ffec:tivcness/Qurlity 'r- Timcless A- Aver T - Timeliness

Adi(ti!al Ratine