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Information Sheet Required For

This document is an information sheet required by Administrative Order 171 for government employees. It collects personal details such as name, civil status, birthdate, education history, work experience, duties, and references. Employees must certify the provided information is true and correct. The purpose is to gather background details on government workers for administrative purposes.

Uploaded by

Gayl Ignacio Tolentino
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© © All Rights Reserved
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376 views3 pages

Information Sheet Required For

This document is an information sheet required by Administrative Order 171 for government employees. It collects personal details such as name, civil status, birthdate, education history, work experience, duties, and references. Employees must certify the provided information is true and correct. The purpose is to gather background details on government workers for administrative purposes.

Uploaded by

Gayl Ignacio Tolentino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INFORMATION SHEET REQUIRED FOR

PURPOSES OF ADIMINSTRATIVE ORDER NO. 171, January 17, 1956

1. Name: Civil Status:

(Family Name) (Given Name) (Middle Name)


2. City: Provincial:

3. Birthdate: Place:

4. Nearest Relative: Provincial:

5. Civil Service Eligibility:


Name of Examination Rating Date

6. Educational Attainment:
Degree College/University Date

7. Board Examination Passed, if any:


Name of Examination Rating Date

8. Technical Training, if any:

9. Special Knowledge, if any:

10. Record of service in the Government (Include fate of original appointment as well as subsequent one,
including the last promotion. Include service in the USAFFE or PA and also service under the U.S.
Government before the granting of the Philippine Independence in July 4, 1946.)

Date Bureau of Office Position Annual Salary Nature of


Work
Performed
Information Sheet
For Administrative Order 171

11. Brief but concise statement of your present duties:

12. Experience outside the Government, if any:

13. In what particular line of service can you be most useful?

14. Are you related to anybody in the Office in which the position you aspire for belongs? If so, state the
degree of relationship.

15. Have you been accused or convicted in court of any crime or are there any criminal or administrative
case filed against you in the court of any government agency? If so, give particulars:
16. Have you been retired under any retirement law or separated from the service?

17. Reference: Give names, address and occupation of two reliable persons
(not related to you who could vouch for your integrity and honesty.)

I hereby certify under oath that the foregoing statements are true and correct:
Date:

Signature of Employee
Present Assignment:

Bureau, Office:

SUBSCRIBED AND SWORN TO before me this day of ,


at , Philippines, affiant
exhibiting to me his/her Residence Certificate No. Issued at
on .

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