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I, ___________________________________________, of legal age, single, Filipino and residing at

__________________________________________________________ after having been duly sworn in accordance with law, do
hereby depose and state that:

1. Each of the document submitted is an authentic and original copy or a true and faithful reproduction of the original, complete
and that all statements and information provided therein true and correct;

2. I am executing this omnibus sworn certification to assure authenticity and veracity of all documents submitted;

3. That I am assuming full responsibility and accountability on the validity and authenticity of the documents submitted:

3.1 CSC Form 212 (Revised 2005) in two copies with the latest 2x2 ID
3.2 Certified photocopy of PRC Certificate of Registration/License
3.3 Certified photocopy of ratings obtained in the Licensure
Examination for Teachers/ Professional Board Examination for
3.4 Certified True Copy of Transcript of Records for Baccalaureate
3.5 Copies of Service Record /Certificate of Employment, Performance
Rating, and School Clearance for those with teaching experience
3.6 Certificates of specialized training, if any
3.7 Certified copy of Voters ID and /or any proof of residency as
deemed acceptable by the School Screening Committee
3.8 NBI Clearance
4 That I am aware that any violation will automatically disqualify me from the selection process;

5 That I am making these statements as part of the requirement for Senior High School Teacher Applicant to the Department
of Education, Division of City Schools, Iligan City for S.Y. 2017-2018.

Printed Name and Signature of Applicant

SUBSCRIBE AND SWORN to before me this _______ day of _____________, 20____, affiant exhibiting to me
his/her Community Tax Certificate No. __________________ issued on ____________________ at
___________________________________________, Philippines.

Notary Public

Until: ____________________________
PTR No.____________________________
Date: ____________________________
Place: ____________________________
TIN: ____________________________

Doc No. ____________________

Page No. ____________________
Book No. ____________________