OMNIBUS SWORN STATEMENT

Republic of the Philippines )

Province of Biliran ) S.S.
Municipality of Naval )

AFFIDAVIT
I, ANGELITO V. PEPITO JR. , of legal age, single/married/widow/widower, Filipino, and
(Name of Applicant/Affiant)

residing at BERNARDES VILL. 1, ATIPOLO, NAVAL, BILIRAN , after having been duly sworn in accordance
with law, do
(Address of Affiant)
hereby depose and state that:

1. I am a bonafide applicant for Teacher 1 position in ____________________________ /

(Name of School and District)
___LARRAZABAL NATIONAL HIGH SCHOOL____________, Division of Biliran;
(Name of Secondary School)
2. I am submitting the following documents together with a written application, to wit:
 CSC Form 212 (Revised 2005) in two copies with the latest 2x2 ID picture
 Certified photocopy of PRC Certificate of Registration/License
 Certified Photocopy of ratings obtained in the Licensure Examination for
Teachers/Professional Board Examination for Teachers
 Certified copies of Transcript of Records for baccalaureate course
 Copies of Service Record, performance rating and school clearance for those with
teaching experience
 Certificates of specialized training, if any
 Certified copy of Voter’s ID
 NBI clearance

3. I am certifying that each of the documents submitted in satisfaction of the requirements for
application is an authentic copy of the original, complete, and all statements and information provided
therein are true and correct;

4. I am authorizing the Chairman and Members of the School Selection Committee to verify all the
documents which I have submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this day of , 2017 at .

ANGELITO V. PEPITO JR.

Applicant/Affiant
PRC ID No. 1605483
Issued on 01 – 05 - 2018
Issued at PRC Tacloban

SUBSCRIBED AND SWORN to before me this _____ day of _______________, 2017 at _____________________,
affiants exhibited to me his/her PRC ID number.

Notary Public
Doc No.
Book No.
Page No.
Series of 2017