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Request for Eligibility/Examination Records:Declaration

CSC request for personel records

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To COE Request

DECLARATION
That, I, _________________________________________________, Filipino citizen, of legal age,
(First, Middle, and Last Name)

_________________, and a resident of ________________________________________, hereby state:
(Civil Status)

(Address)

That, I am a _______________________________ eligible. My eligibility was issued/granted by the
*(Type of Eligibility/Examination)

Civil Service Commission _____________________________________ on _________________________.
(Central/Regional Office or Place of Issuance/Exam)

(Date of Issuance/Exam)

(Please read Categories A-C and check/choose 1 ONLY.)

A. That, I lost my Report of Rating (ROR) or Certificate of Eligibility (COE) on ___________________,
because of:
(Date)
_____theft
_____flood/typhoon
_____other reason/s
_____fire
_____transfer of residence
_____________________
_____termites
_____misplacement/negligence
_____________________
That, despite diligent search and efforts to locate the said ROR/COE, I could not find the same such
that I believe it is lost and beyond recovery.
B. That, I am not in possession of my Report of Rating (ROR) or Certificate of Eligibility (COE), because:
_____I did not receive/claim/pick-up my ROR or COE
_____I submitted my ROR or COE to the agency/employer
C. That, I want to replace my Report of Rating or Certificate of Eligibility, because:
_____it is old/torn/worn-out
_____my request for correction of my personal information has been duly granted by the CSC
That, I am executing this Declaration to attest to the truth of the foregoing, and, in support of my
request for certification of my eligibility. Under oath, I declare under penalty of perjury that this has been
accomplished by me, and is true, correct and complete statement pursuant to the provisions of pertinent
laws, rules and regulations of the Republic of the Philippines.

____________________________

______________

(Signature of Eligible/Examinee)

(Date)

Identification Cards presented:
Issued by:
1 ______________________
2 ______________________

(Right Thumb Print)

Issued at:
_____________________
_____________________

Date of Issuance:
_____________________
_____________________

NOTE: ALL DETAILS FROM NAME TO IDENTIFICATION CARDS PRESENTED
SHOULD BE ACCOMPLISHED BY THE ELIGIBLE/EXAMINEE
*e.g.

Career Service Professional/Subprofessional
Police Officer / Police Officer I
Professional Board Examination for Teachers
Fire Officer / Penology Officer

PD 907
Barangay Official
Stenographer
Agricultural Officer

RA 1080 (Professional/Subprofessional/Teacher)
MC 11 (Data Encoder, Plumber, Carpenter, etc.)
Res. 435 (Security Guard, Messenger, etc.)
Others
Revised 01192011
 
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