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Instructions: This form is an ofcial document. Please

answer all items. If an item is
not applicable to you, indicate NA or Not Applicable.
Please check ( the appropriate bo! whene"er applicable.
Position Applied For: Have you taken BSP pre-employment
test before? Yes
No
1. SURNAME FIRST NAME
MIDDLE NAME
For female married applicant: write Maiden
Name
2. I!IL STATUS ". #ENDER

Male
Female
$. ITI%ENS&I'

Sngle Marre! Separate!
"!o#er$"!o#
(. DATE )F *IRT& +. A#E ,. 'LAE )F *IRT& -. &EI#&T .Meter/0 1. 2EI#&T .3ilo/0
14. 'ERMANENT ADDRESS 11. E5MAIL ADDRESS 12. )NTAT NUM*ER
1".
EDUATI)N
Name and Addre// of
Sc6ool7olle8e7 Uni9er/it:
o;r/e
%&f 'n!ergra!uate( n!)ate
no. of unts )omplete!*
Incl;/i9e
Date/ of
Attendance
&onor/
Recei9ed
Secondar:
!ocational
olle8e
'o/t8rad;at
e
(#ontinue on separate sheet, if necessary
1$. I!IL SER!IE
ELI#I*ILIT<7LIENSE
./pecif: if *)ARD= *AR= etc.0
Ratin
g
1(. S3ILLS AND )T&ER
>UALIFIATI)NS
1+. MEM*ERS&I' IN
RELATED ASS)IATI)N=
&)**IES= etc.
(#ontinue on separate sheet, if necessary
1,. SEMINAR7TRAININ# ATTENDED
Title of Seminar7 Trainin8 Incl;/i9e Date/
No. of
&o;r/
(#ontinue on separate sheet, if necessary
1-. EM'L)<MENT &IST)R<
Incl;/i9e date/
.E?act date/0
'o/ition Title and
Stat;/ of Appointment
%spe)fy f Permanent(
Probatonary +emporary(
,asual( ,ontra)tual( et).*
Name and Addre// of
ompan:7A8enc:7)@ce
Mont6l:
Rea/on for
Lea9in8
*a/ic
Salar:
Allowanc
e/
H- Form No. ./-..1 %01M Form No..1-.2.* 3 4erson5 6 3 'p!ate!5 3. 0ugust /.1/
A''LIATI)N F)R EM'L)<MENT
'ict;re
.'a//port
/iAe0
Page / of 3
(#ontinue on separate sheet, if necessary
11. 0re you relate! to any o7)al or employee n t8e
BSP5

a.* #t8n t8e t8r! !egree of )onsangunty %.e.
mot8er$fat8er( son$!aug8ter( brot8er$sster(
nep8e#$ne)e( un)le$aunt( gran!parent(
gran!)8l!*? Yes No
b.* #t8n t8e se)on! !egree of a7nty %.e. mot8er-n-
la#$ fat8er-n-la#( son-n-la#$!aug8ter-n-la#( brot8er-
n-la#$ sster-n-la#*?

Yes No
).* ot8er relatve$s not spe)9e! n tems a an! B?
Yes No
&f yes( gve name$s of relatve$s an! relatons8p$s

&f yes( gve name$s of relatve$s an! relatons8p$s
&f yes( gve name$s of relatve$s an! relatons8p$s
24. :o you 8ave relatve$s #8o #as$#ere former
employee$s of t8e
Bangko Sentral ng Plpnas? Yes No
&f yes( gve name$s( relatons8p( !epartment an!
!ate of retrement
21. Have you ever been a respon!ent for a prelmnary
nvestgaton
before t8e Prose)utor;s$ Fs)al;s 17)e or any la#
enfor)ement
agen)y su)8 as t8e pol)e( P:<0( NB&( et).?
Yes No
&f =Yes>( state nature of t8e o?ense )omplane! of
Stat;/:

1n-gong

:smsse!
22. Have you ever been )8arge! of
a* an a!mnstratve )ase? Yes No
b* a )rmnal )ase? Yes
No
&f =Yes>( state nature of o?ense$)rme
Stat;/:
1n-
gong

0)@utte!

:smsse!
2". Have you ever been )onv)te! of any a!mnstratve
o?ense
or )rme? Yes No
&f =Yes>( state nature of t8e o?ense$)ase an!
penalty
2$. Have you ever been retre!( for)e! to resgn or
!roppe! from
employment #8et8er n t8e publ) or prvate se)tor?
Yes No
&f =Yes>( gve reasons
2(. Have you ever been a )an!!ate n a natonal or
lo)al ele)ton
%eA)ept Barangay ele)ton*? Yes No
&f BYesB( gve !etals
2+. Please )8e)k any alment$s for #8)8 you 8ave been treate! or are presently un!ergong treatment
8ypertenson )8ron) pulmonary !sease 8ematolog) )on!ton
!abetes malgnan)es$)an)er )8ron) lver !sease
a)@ure! 8eart
!sease
autommune !sease
maCor )ongental
anomaly$!eformaton
k!ney !sease
)ar!ovas)ular 0))!ent
%,40*
ot8ers5 DDDDDDDDDDDDDDDDDDDDDDDDDDDDD
pulmonary neuro-psy)8atr) )on!ton
H- Form No. ./-..1 %01M Form No..1-.2.* 3 4erson5 6 3 'p!ate!5 3. 0ugust /.1/
Page 3 of 3
tuber)uloss DDDDDDDDDDDDDDDDDDDDDDDDDDDDD
2,. "8at s t8e mnmum
salary
you are #llng to
a))ept?
2-. FOR APPLICANTS TO A SECURITY GUARD POSITION ONLY
&f )ons!ere!( are you #llng to be assgne!$re-assgne! to t8e Man$SP,$regonal
o7)es$bran)8es of t8e Bangko Sentral ng Plpnas n t8e performan)e of your Cob?

Yes No Sgnature
DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
21. REFERENES %Persons not relate! by )onsangunty or a7nty to appl)ant*
Name
Addre//7 Telep6one No.
1. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
/. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
3. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
I declare t6at t6e an/wer/ 8i9en aBo9e are tr;e and correct to t6e Be/t of m: Cnowled8e
and Belief. It i/ ;nder/tood t6at an: fal/e repre/entation I made aBo9e /6all di/D;alif: me from
emplo:ment in t6e *S' in w6ic6 ca/e= m: appointment= if one i/ i//;ed= /6all Be re9oCedE /;c6
repre/entation /6all Be a 8ro;nd for an admini/trati9e ca/e for DIS&)NEST< and7or )NDUT
'REFUDIIAL T) T&E *EST INTEREST )F T&E SER!IE p;ni/6aBle ;nder t6e di/ciplinar: r;le/ on
admini/trati9e ca/e/ Bot6 in i9il Ser9ice ommi//ion and *S'.
I f;rt6er wai9e m: ri86t to conGdentialit: of information pertainin8 to t6e *S' 2atc6li/t
clearance in compliance wit6
M.*. Re/ol;tion No. 1$-,.
Si8nat;re o9er 'rinted Name7 Date
omm;nit: Ta? ertiGcate No.
HHHHHHHHHHHHHHHH
I//;ed at
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
I//;ed on
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
H- Form No. ./-..1 %01M Form No..1-.2.* 3 4erson5 6 3 'p!ate!5 3. 0ugust /.1/