Application Form and Sample Sheet
Application Form and Sample Sheet
Residence: ________________________________________________________________________________
YES NO
Symptoms (Mga sintomas)
(Oo) (Hindi)
1. Are you currently a. Sore throat (Pananakit ng lalamunan/masakit lumunok)
experiencing
b. Shortness of Breath (Hirap sa paghinga)
symptoms, or have
experienced, within c. Body pains (Pananakit ng katawan)
the last 14 days:
d. Headache (Pananakit ng ulo)
(Kasalukuyan ka bang e. Fever for the past few days (Lagnat sa mga nakalipas na araw)
nakakaranas ng sintomas
o nakaranas sa huling 14 f. Loss of taste or smell (Pagkawala ng panlasa o pang-amoy)
na araw)
g. Cough and/or cold (Ubo at/o sipon)
h. Diarrhea (Pagtatae)
2. Have you worked together or stayed in the same household/ close environment with a
confirmed COVID-19 case?
(May nakasama ka ba or nakatrabahong tao na kumpimadong COVID-19 case/may impeksyon ng
COVID-19?)
3. Are you living with a household member who is currently waiting for results of his/her
swab test/ COVID-19 test?
(Ikaw ba ay may kasama sa bahay na nag-aantay ng resulta ng swab test/ COVID-19 test?)
4. Have you had any contact with anyone or living with household member with fever,
cough, colds, sore throat, loss of taste or smell in the past 2 weeks?
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas ng
dalawang (2) linggo?)
5. Have you travelled outside of the Philippines within the last 14 days?
(Ikaw ba ay nagbiyahe sa labas ng Pilipinas sa nakalipas na 14 na araw?)
I declare under oath that I personally accomplished this Health Declaration form. Further, I declare that the
information given are true, correct, and complete statements pursuant to the provisions of pertinent laws, rules,
and regulations of the Republic of the Philippines.
I hereby authorize the CIVIL SERVICE COMMISSION (CSC), to collect and process the data indicated herein for
the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected
by RA 10173, Data Privacy Act of 2012, and that I am required by RA No. 11469, Bayanihan to Heal as One Act,
as amended by RA 11494, to provide truthful information. Further, I understand that any false information may
have serious public health implications and may be subjected to legal consequences. Finally, I understand that, in
case I would test positive for COVID-19 within 14 days after the exam day, the CSC shall, upon request of the
LGU/Barangay concerned, provide my necessary/pertinent information for contact tracing.
Signature: __________________________________
Annex A1
CS FORM No. 100, Revised 2023. This Form is NOT for sale. Reproduction is allowed. APPLICATION NO. _______________
Instructions : READ ADMISSION AND APPLICATION REQUIREMENTS AT THE BACK PAGE. DO NOT APPLY IF NOT QUALIFIED.
Fill in all the required information. DO NOT leave an item blank. If item is not applicable, indicate “N/A”.
NAME (Last Name) (Given Name) (Ext. Name, e.g. Jr./Sr., if any) (Middle Name) (M.I.)
(e.g. De La Paz = D, P, or DLP; Dela Paz = D, P, or DP)
AGE DATE OF BIRTH (mm/dd/yyyy) SEX PLACE OF BIRTH: City (write province only if city name has namesake e.g. San Fernando City, La Union/City of San Fernando, Pampanga; OR Municipality & Province
Male Female
CITIZENSHIP MOTHER’S MAIDEN FULL NAME (the full name of your mother by birth or before she was married)
(Last Name) (Given Name) (Middle Name)
CIVIL STATUS OTHER DATA: If PWD, please specify: Orthopedic Deaf/hard of hearing
Single Married Others _____________________ Pregnant Senior Citizen Visually impaired Others ___________________________________________
MOBILE NUMBER (Required) TELEPHONE NUMBER (include Area Code) E-MAIL ADDRESS (Required)
Level of Education: High School/Sr High School Technical/Vocational College Postgraduate (Master/Doctor) Other/s: _______________________________
Complete Title of Course/Degree (except for High School/Sr High School): ___________________________________________ Major: ______________________________________
Title of Examination Passed / Title of Eligibility Granted Rating Obtained Date of Examination / Place of Examination
Date Eligibility was Granted
Date: ________________
Identification/Other Documents Presented: _______________________________________ Details: ______________________________________
O.R. No. _____________
ACTION TAKEN: APPROVED DISAPPROVED Reason for disapproval: ________________________________________
Amount: _____________
E. DECLARATION
I declare that I personally accomplished this application form, and I certify that the information given are true, correct, and complete statements pursuant to the
provisions of pertinent laws, rules, and regulations of the Republic of the Philippines. Further, I declare that I meet and am compliant with ALL the admission
requirements for the examination herein applied for, as enumerated below.
I understand that the acceptance and approval of my application for the examination is based on the information I provided. Further, I understand that: 1) as a result
of randomization procedure, I may and am willing to be assigned at any testing venue within the testing center; and 2) the information I provided herein shall be
handled and used, particularly for policy development/review/research/study purposes, according to appropriate provisions of RA No. 10173 or the Data Privacy Act
of 2012. Finally, I understand that the CSC determines high answer similarities in the processing of test results, and conducts necessary investigation.
I therefore agree that: 1) in case a post-verification yields information contrary to what is declared, my application shall be disapproved, and my payment forfeited; 2)
any misrepresentation made in this document shall cause the invalidation of the result of this examination and/or the filing of administrative/criminal case/s against
me; and 3) in case my test results be found to have high answer similarities with other examinee/s, the same shall be withheld pending the outcome of the
investigation to be conducted by the CSC. Finally, I agree that my examination shall not be processed and be considered null and void, or my test results shall be
cancelled, in case a post-examination verification shows that I violated Republic Act No. 9416 (Anti-Cheating Law), specifically the unauthorized possession of the
test booklet, or any examination related forms/materials, including bringing of the same outside of the testing room/venue.
__________________________________________________________________ _____________________________________
Signature over Printed Name of Applicant Date
Please check related Examination Announcement for additional and/or updates on admission requirements and/or application requirements.
A. Place of Examination (School/Testing Venue Assignment) - shall be announced through the Online Notice of School Assignment (ONSA), available via the CSC website
www.csc.gov.ph approximately 2 weeks before examination day. If ONSA cannot be accessed, visit or call and inquire directly with the CSC Regional/Field Office where the
examinees filed their application. A complete directory of CSC Regional/Field Offices nationwide is available at the CSC website.
B. Ocular Inspection - visit and conduct an ocular inspection of the assigned school/testing venue at least 1 day before the exam day to be familiar with the school location
C. Failure to come on scheduled examination will mean forfeiture of examination fee and slot. Rescheduling of examination date is NOT allowed.
D. THINGS TO BRING ON EXAMINATION DAY [Note: Examinees are (i) advised to bring ONLY the items listed below, (ii) encouraged to use transparent bag, and (iii) to check related
Exam Advisory for additional and/or updates on Things to Bring on Exam Day.]
1. I.D. card, preferably the same I.D. card presented during filing of application (NO I.D., NO EXAM)
2. BLACK BALLPEN/S (note: Pencils and any other kinds of pen such as gel pen, sign pen, fountain pen, friction pen, etc. including other colors of ball pen are not allowed)
3. Original of PSA/LCR issued Birth Certificate (only if I.D. card has no date of birth)
Note: Examinees may opt to bring water, or preferred beverage (except alcoholic beverage) placed in clear/transparent container, and/or candies/biscuits (subject to inspection by the Room Examiner/Proctor)
E. Wear proper attire on exam day, preferably plain white shirt/tops. SLEEVELESS SHIRT/BLOUSE, SHORTS/SHORT PANTS, TOKONG PANTS, RIPPED JEANS, and SLIPPERS
ARE NOT ALLOWED. Long hair (for both male and female) must be tied in “ponytail.”
F. Cellular phones and calculators are NOT ALLOWED in EXAMINEE’S SEAT, and any other gadgets including smart phones/watches and pens/eyeglasses with built-in camera,
wristwatches with calculator, books and other forms of printed materials, and any other items/tools/aids that would facilitate answering the test questions. In this regard, before
occupying the assigned seat, examinees shall deposit said items and their bags and all other personal belongings in front of the room or in the designated area. NO BELONGINGS
SHOULD BE PLACED UNDER THE EXAMINEE’S SEAT.
IMPORTANT: Access, read thoroughly, and understand fully the EXAMINEE’S GUIDE on the conduct of the exam.
Annex A2
CS FORM No. 100, Revised 2023. This Form is NOT for sale. Reproduction is allowed. APPLICATION NO. _______________
Instructions : READ ADMISSION AND APPLICATION REQUIREMENTS AT THE BACK PAGE. DO NOT APPLY IF NOT QUALIFIED.
Fill in all the required information. DO NOT leave an item blank. If item is not applicable, indicate “N/A”.
NAME (Last Name) (Given Name) (Ext. Name, e.g. Jr./Sr., if any) (Middle Name) (M.I.)
(e.g. De La Paz = D, P, or DLP; Dela Paz = D, P, or DP)
AGE DATE OF BIRTH (mm/dd/yyyy) SEX PLACE OF BIRTH: City (write province only if city name has namesake e.g. San Fernando City, La Union/City of San Fernando, Pampanga; OR Municipality & Province
Male Female
CITIZENSHIP MOTHER’S MAIDEN FULL NAME (the full name of your mother by birth or before she was married)
(Last Name) (Given Name) (Middle Name)
CIVIL STATUS OTHER DATA: If PWD, please specify: Orthopedic Deaf/hard of hearing
Single Married Others _____________________ Pregnant Senior Citizen Visually impaired Others ___________________________________________
MOBILE NUMBER (Required) TELEPHONE NUMBER (include Area Code) E-MAIL ADDRESS (Required)
Level of Education: High School/Sr High School Technical/Vocational College Postgraduate (Master/Doctor) Other/s: _______________________________
Completion: If not graduated/ongoing, highest Year/Level/Units earned, or taking up: ___________________________________
Not Graduated / ongoing
Graduated If graduated, date/year of Graduation/Completion: _______________________ Honors received: ______________________________
Complete Title of Course/Degree (except for High School/Sr High School): ___________________________________________ Major: ______________________________________
Title of Examination Passed / Title of Eligibility Granted Rating Obtained Date of Examination / Place of Examination
Date Eligibility was Granted
DO NOT FILL OUT THE SHADED PORTION. (FOR CSC PROCESSOR ONLY).
Date: ________________
Identification/Other Documents Presented: _______________________________________ Details: ______________________________________
O.R. No. _____________
ACTION TAKEN: APPROVED DISAPPROVED Reason for disapproval: ________________________________________
Amount: _____________
E. DECLARATION
I declare that I personally accomplished this application form, and I certify that the information given are true, correct, and complete statements pursuant to the
provisions of pertinent laws, rules, and regulations of the Republic of the Philippines. Further, I declare that I meet and am compliant with ALL the admission
requirements for the examination herein applied for, as enumerated below.
I understand that the acceptance and approval of my application for the examination is based on the information I provided. Further, I understand that: 1) as a result
of randomization procedure, I may and am willing to be assigned at any testing venue within the testing center; and 2) the information I provided herein shall be
handled and used, particularly for policy development/review/research/study purposes, according to appropriate provisions of RA No. 10173 or the Data Privacy Act
of 2012. Finally, I understand that the CSC determines high answer similarities in the processing of test results, and conducts necessary investigation.
I therefore agree that: 1) in case a post-verification yields information contrary to what is declared, my application shall be disapproved, and my payment forfeited; 2)
any misrepresentation made in this document shall cause the invalidation of the result of this examination and/or the filing of administrative/criminal case/s against
me; and 3) in case my test results be found to have high answer similarities with other examinee/s, the same shall be withheld pending the outcome of the
investigation to be conducted by the CSC. Finally, I agree that my examination shall not be processed and be considered null and void, or my test results shall be
cancelled, in case a post-examination verification shows that I violated Republic Act No. 9416 (Anti-Cheating Law), specifically the unauthorized possession of the
test booklet, or any examination related forms/materials, including bringing of the same outside of the testing room/venue.
__________________________________________________________________ _____________________________________
Signature over Printed Name of Applicant Date
Please check related Examination Announcement for additional and/or updates on admission requirements and/or application requirements.
A. Place of Examination (School/Testing Venue Assignment) - shall be announced through the Online Notice of School Assignment (ONSA), available via the CSC website
www.csc.gov.ph approximately 2 weeks before examination day. If ONSA cannot be accessed, visit or call and inquire directly with the CSC Regional/Field Office where the
examinees filed their application. A complete directory of CSC Regional/Field Offices nationwide is available at the CSC website.
B. Ocular Inspection - visit and conduct an ocular inspection of the assigned school/testing venue at least 1 day before the exam day to be familiar with the school location
C. Failure to come on scheduled examination will mean forfeiture of examination fee and slot. Rescheduling of examination date is NOT allowed.
D. THINGS TO BRING ON EXAMINATION DAY [Note: Examinees are (i) advised to bring ONLY the items listed below, (ii) encouraged to use transparent bag, and (iii) to check
related Exam Advisory for additional and/or updates on Things to Bring on Exam Day.]
1. I.D. card, preferably the same I.D. card presented during filing of application (NO I.D., NO EXAM)
2. BLACK BALLPEN/S (note: Pencils and any other kinds of pen such as gel pen, sign pen, fountain pen, friction pen, etc. including other colors of ball pen are not allowed)
3. Original of PSA/LCR issued Birth Certificate (only if I.D. card has no date of birth)
Note: Examinees may opt to bring water, or preferred beverage (except alcoholic beverage) placed in clear/transparent container, and/or candies/biscuits (subject to inspection by the Room Examiner/Proctor)
E. Wear proper attire on exam day, preferably plain white shirt/tops. SLEEVELESS SHIRT/BLOUSE, SHORTS/SHORT PANTS, TOKONG PANTS, RIPPED JEANS, and SLIPPERS
ARE NOT ALLOWED. Long hair (for both male and female) must be tied in “ponytail.”
F. Cellular phones and calculators are NOT ALLOWED in EXAMINEE’S SEAT, and any other gadgets including smart phones/watches and pens/eyeglasses with built-in camera,
wristwatches with calculator, books and other forms of printed materials, and any other items/tools/aids that would facilitate answering the test questions. In this regard, before
occupying the assigned seat, examinees shall deposit said items and their bags and all other personal belongings in front of the room or in the designated area. NO BELONGINGS
SHOULD BE PLACED UNDER THE EXAMINEE’S SEAT.
IMPORTANT: Access, read thoroughly, and understand fully the EXAMINEE’S GUIDE on the conduct of the exam.
CERTIFICATE OF CONSENT
3. I am fully aware of the continuing existence of the Corona Virus Disease (COVID-19)
and its potential health threats/risks.
4. I understand that all known precautions and health safety protocols, in accordance
with the Omnibus Guidelines of the Inter-Agency Task Force (IATF) for the
Management of Emerging Infectious Diseases, to ensure my safety are
taken/instituted by the CSC in and for the conduct of the examination.
With my full knowledge and understanding of the above declarations, I hereby wholly give
my consent and confirm my participation on my own free will and volition in the conduct of
the _______________________________________________ on ___________________.
(Title of Examination) (Date of Examination)
Accordingly, I set CSC entirely free from any liability or responsibility in the event that I
contract COVID-19 during the period of the aforementioned examination.
___________________________________________ _____________
Signature over printed full name of examinee/examiner Date
___________________________________________ _____________
Signature over printed full name of witness Date