Republika ng Pilipinas

KAGAWARAN NG EDUKASYON
Rehiyon XI
SANGAY NG COMPOSTELA VALLEY
Nabunturan

Municipality : School : District :

Name: Date of Birth: Sex :
(Surname) (Given Name) (M.I.)
Employee No. Item Number : Authorized Position Title:
Page Number : Authorized Salary:
I. EDUCATIONAL ATTAINMENT AND ELIGIBILITY:
Title, Degree or Highest Grade Name of Institution Year Received Eligibility Rating Date
Attained

II. SERVICE RECORD: Attached duly certified service record

III. EQUIVALENT UNITS:
A. Total No. of Years Teaching (public only) years. Equivalent :
B. Degree to Degree Equivalent (present degree) M.A. Units Equivalent :

C. Areas of Equivalent School Year No. of Units/Years Description

1. Professional Study

TOTAL
2. Teaching Experience
a. Public school

3. Others:

Latest Efficiency Rating:

Teacher's Signature
APPROVAL RECOMMENDED:
Public Schools District Supervisor
IV. DIVISION ACTION:
CLASSIFICATION Date Processed Range Assignment Salary Grade Scheduled Salary Remarks

CERTIFIED CORRECT: NORBERTO S. MANLANGIT, MPA JOSIE T. BOLOFER, Ed. D

Administrative Officer V Chief Education Supervisor
Evaluator OIC-Assistant Schools Division Superintendent
APPROVED:

REYNANTE A. SOLITARIO, Ed. D.

Officer-In-Charge
Office of the Schools Division Superintendent

O A T H
I hereby certify under oath that I have actually enrolled in the school(s) listed in the accompanying Transcript of
Records and that I have earned the units indicated therein.

SIGNATURE OVER PRINTED NAME

SUBSCRIBED AND SWORN TO BEFORE ME this __________________________, affiant exhibiting his/her

Community Tax Certificate No. _________________ issued at __________________________ on
______________________.
Notary Public