FEU ROOSEVELT Human Resource Department

APPLICATION FOR EMPLOYMENT

INSTRUCTIONS:
• Please PRINT all necessary information. POSITION APPLIED FOR:
• Use black ink. Part Time Faculty (Filipino)
• Check box or answer all questions completely and accurately. _____________________________________ RECENT
• Do not leave any questions/blanks unanswered. 2 x 2
• If a question does not apply to you, please indicate “N.A.” or DATE OF APPLICATION:
NOT APPLICABLE. 27 June 2023 PHOTO
• Data reflected in this form will be maintained in strictest ____________________________________
confidence.
PERSONAL BACKGROUND
LAST NAME FIRST MIDDLE GENDER CONTACT NUMBERS
GOMEZ GLENN BALIWAS / Male Female Landline:
CITY ADDRESS (No., Street, Barangay, City/Town, Province, Zipcode) Mobile: 09328705353
196 ORTIGAS EXT. STA LUCIA, PASIG CITY E-Mail:
PROVINCIAL ADDRESS (No., Street, Barangay, City/Town, Province, Zipcode)
[email protected]

BIRTH DATE / AGE (Optional) BIRTH PLACE HEIGHT WEIGHT BLOOD TYPE
11/11/1990 32 Y/O DAET, CAMARINES NORTE 5’7 68 KG
CITIZENSHIP RELIGION CIVIL STATUS
FILIPINO ROMAN CATHOLIC / Single Married Widowed/er Separated
Tax Identification Number SSS Number PHILHEALTH Number PAG-IBIG Number
411-678-889 34-2580209-7 0305-0874-1568 1210-0953-6746
PERSON TO NOTIFY IN CASE OF EMERGENCY: RELATION CONTACT DETAILS
NAME Landline:
TERESA GOMEZ-ABUYA
SISTER Mobile: 09307048129
FAMILY INFORMATION
(Include spouse, children, parents, and siblings. Use additional sheets necessary.)
NAME RELATIONSHIP BIRTH CIVIL E-MAIL ADDRESS / EMPLOYER/POSITION
DATE STATUS CONTACT NOS. OR SCHOOL
ORLANDO GOMEZ FATHER 11/17/1945 M
NENITA GOMEZ MOTHER 12/16/1945 M
MERCY GOMEZ SISTER 05/25/1967 S
TERESA ABUYA SISTER 08/24/1976 M
EDUCATIONAL / TRAINING BACKGROUND
NAME OF SCHOOL / ADDRESS ACADEMIC DEGREE MAJOR SCHOOL YEAR HONORS/AWARDS
PROGRAM RECEIVED
From To
DOCTORATE DEGREE

MASTER’S DEGREE
NATIONAL TEACHER COLLEGE MAED FILIPINO 2019 2022
UNIV. OF THE PHILIPPINES - DILIMAN MA ARALING PILIPINO (CAND.) 2012 PRESENT
BACHELOR’S DEGREE
BSE FILIPINO
PHILIPPINE NORMAL UNIVERSITY - MANILA 2007 2011 CUM LAUDE
UG CERTIFICATE IN READING
VOCATIONAL/OTHER COURSES TAKEN

HIGH SCHOOL
QUEZON CITY HIGH SCHOOL 2004 2007 SALUTATORIAN
ELEMENTARY
DAET ELEMENTARY SCHOOL 1997 2004

GOVERNMENT EXAMS, LICENSURE Title of Exam/Licensure/Certification Year Taken Rating

and CERTIFICATIONS SUB-PROFESSIONAL CIVIL SERVICE 2008
LICENSURE EXAM FOR TEACHERS 2011
OTHER AWARDS AND Title/Name of the Award Year Awarded Award Giving Body/Sponsor
ACHIEVEMENT PLEASE SEE ATTACHED
DOCUMENTS
TRAININGS/ SEMINARS/ NUMBER
CONFERENCES/OTHERS ORGANIZER START END OF TYPE ROLE VENUE
Use additional sheets as necessary DATE DATE HOURS
PLEASE SEE ATTACHED DOCUMENTS

FEUR-HRD-QSF. Revision No. – 00 Effectivity Date: 09 July 2019

OTHER SKILLS AND LEVEL OF PROFICIENCY
(Computer operation, language spoken/written, familiarity with office equipment/ machines)
READING, WRITING, RESEARCH IN FILIPINO LANGUAGE AND
LITERATURE

EMPLOYMENT BACKGROUND (Start with the latest employer. Use additional sheets as necessary.)
DATE LAST REASON FOR COMMENDATION AND
EMPLOYER From To SALARY LEAVING/ OTHER RECOGNITION
Text RECEIVED SEPARATION RECEIVED
Name of Company: XAVIER SCHOOL 2011 PRESENT
Address/Tel.No.: 64 XAVIER ST. GREENHILLS WEST,
SAN JUAN CITY
Last Position/Rank & Department: COORDINATOR, JHS FILIPINO
Name of Company:
Add/Tel.No.:
Last Position/Rank & Department:
COMMUNITY EXTENSION SERVICES (Use additional sheets as necessary.)
PROJECT NAME/TITLE DESCRIPTION ROLE PERIOD SPONSOR
COVERED
PLEASE SEE ATTACHED DOCUMENTS

MEMBERSHIP IN PROFESSIONAL AND CIVIC ORGANIZATIONS (Use additional sheets as necessary.)

NAME OF ORGANIZATION NATURE OF NATURE OF PARTICAPATION/ PERIOD COVERED
ORGANIZATION ACTIVITIES UNDERTAKEN
PLEASE SEE ATTACHED DOCUMENTS

PUBLICATION/RESEARCH WORK/CREATIVE OUTPUTS (Use additional sheets as necessary.)

TYPE TITLE NAME OF YEAR PUBLISHED PUBLISHER
JOURNAL/BOOK
PLEASE SEE ATTACHED DOCUMENTS

REFERENCES (Your references should not be related to you and must have known you personally for at least 2 years.)
NAME POSITION COMPANY/ SCHOOL ADDRESS CONTACT
NUMBER/S
JOEL HAWOD COORDINATOR, JHS SCIENCE XAVIER SCHOOL 64 XAVIER ST. 8723-0481
IRENE YCOY SCIENCE TEACHER XAVIER SCHOOL GREENHILLS WEST,
JESSIE ANG CHINESE TEACHER XAVIER SCHOOL SAN JUAN CITY
OTHER INFORMATION
How did you come to apply in this school? Are you available for: YES NO
Full Time Employment /
THROUGH FACEBOOK ADS
Part Time Employment /
Do you expect to engage in any other business or work while employed in Temporary employment /
our school? ________ If yes, give particulars and hours required.
YES, MY REGULAR TEACHING JOB IN XAVIER SCHOOL
___________________________________________________________ What is your salary expectation? _____________________________
___________________________________________________________ Date of availability: ________________________________________
CAN START IMMEDIATELY

Do you have any relative/s employed with FEU Roosevelt? If Have you ever been accused, indicted and/or convicted of any crime?
yes, state the name/s and your relationship: ________. If yes, state facts. _________________________________
N/A
___________________________________________________________ N/A
_________________________________________________________
___________________________________________________________ _________________________________________________________

Have you ever been discharged or requested to resign from any job? Describe any serious illness you had or any handicap you have:
________.
N/A If yes, give particulars. _______________________________ _________________________________________________________
N/A
___________________________________________________________ _________________________________________________________

PRE-EMPLOYMENT STATEMENT
The answers to above questions are true and correct to the best of my knowledge and ability. I voluntarily give FEU Roosevelt the right to carry out
whatever investigation it may consider necessary based on the above answers, and I undertake to provide any assistance which I may be asked to
render. I consent to take whatever medical examination or tests the school may require. If hired, I agree to work in any unit designated by the school.
Finally, I understand that any false answers to the above questions, or false statements in the course of the interview, subsequently discovered to be
false or inaccurate will be sufficient grounds to immediate discharge.

I likewise authorize willingly and voluntarily give my consent, without compulsion and intimidation to FEU Roosevelt or any of its authorized
representatives to process and provide any pertinent data and information, including sensitive personal information available in connection with my
application.
GLENN B. GOMEZ
______________________________________________ 27 JUNE 2023
_____________________
Signature over Printed Name of Applicant Date
FEUR--HRD-QSF. Revision No. – 00 Effectivity Date: 09 July 2019