S EA RC H F OR N O M I NEE S T O T H E 13 & 14 CONGRESSIONAL INTERNSHIP PROGRAM FOR YOUNG MINDANAO LEADERS
TH TH
APPLICATION FORM
INSTRUCTIONS: Please fill up this form in TRIPLICATE and submit on or before April 30, 2012. This document is in MS Word. If necessary, you may insert additional ROW per item entry. For uniformity, please do not alter the fonts face and type in this application form. Documents and certifications submitted may be crosschecked and verified by Program Management.
1. PERSONAL INFORMATION
LAST NAME FIRST NAME MIDDLE NAME
HOME ADDRESS
RES. TEL. NO.
CELL. NO.
FAX NO.
E-MAIL
DATE OF BIRTH
PLACE OF BIRTH
AGE
CITIZENSHIP
CIVIL STATUS
GENDER
IF MARRIED, NAME OF SPOUSE (cell No. of Spouse: ____________________________________) LAST NAME FIRST NAME MIDDLE NAME OCCUPATION
CHILDREN LAST NAME FIRST NAME MIDDLE NAME AGE
PARENTS INFORMATION (Fathers Cell No. ______________________________; Mothers Cell No. __________________________) LAST NAME FIRST NAME MIDDLE NAME OCCUPATION
ARE YOU RELATED TO ANY PERSON/ OFFICIAL DIRECTLY IMPLEMENTING THE CIPYML PROGRAM? (MSU Officials, House of Representatives, GEM Program, UP-NCPAG) ________ (YES) ___________ (NO).
Please note that applicants related to any official/ employee, up to the 4th degree of consanguinity (i.e. first cousins), are automatically disqualified to join the program.) IF YES, PLEASE PROVIDE INFORMATION BELOW: LAST NAME COMPANY/ INSTITUTION POSTION RELATIONSHIP
2. EMPLOYMENT HISTORY (Attach evidence/s of employment)
IF CURRENTLY EMPLOYED, NAME OF OFFICE ADDRESS POSITION
EMPLOYMENT HISTORY POSITION GENERAL JOB DESCRIPTION ORGANIZATION INCLUSIVE DATES
3.
EDUCATION AND TRAINING (Please submit authentic copy of Transcript of Records)
LEVEL SCHOOL/ ADDRESS COURSE INCLUSIVE DATES
EDUCATION Elementary High School Vocational College Graduate Studies/ Post Baccalaureate GPA in College OTHER TRAINING PROGRAMS ATTENDED TRAINING PROGRAM INSTITUTION INCLUSIVE DATES
GPA in Graduate Studies or PostBaccalaureate Degree
4. COMPUTER LITERACY LEVEL (Please check your appropriate answer.)
A. B. Are you a computer literate? ___ Yes ____ No
If Yes, what is your level of literacy/ proficiency in the scale of 1-5, where 5 is the highest? 1 SCALE OF 1-5 where five is the most proficient. 2 3 4 5
Program Microsoft Office Word Microsoft Power point & Presentation Web Designing Internet Access others, please specify: ______________________________
5. ACADEMIC HONORS AND AWARDS RECEIVED (Attach appropriate documents/certifications)
A. NATIONAL LEVEL NATURE OF HONOR/ AWARD AWARD-GIVING BODY
YEAR/ DATE
B.
REGIONAL LEVEL NATURE OF HONOR/ AWARD AWARD-GIVING BODY
YEAR/ DATE
C.
PROVINCIAL, CITY OR UNIVERSITY LEVEL NATURE OF HONOR/ AWARD AWARD-GIVING BODY
YEAR/ DATE
D.
MUNICIPAL OR COLLEGE LEVEL NATURE OF HONOR/ AWARD AWARD-GIVING BODY
YEAR/ DATE
6. LEADERSHIP POSITIONS HELD (Attach appropriate documents/certifications)
Please provide us with a list of positions you have occupied, name of the organization and year of incumbency. A. NATIONAL LEVEL YEAR POSITION ORGANIZATION
B.
REGIONAL LEVEL YEAR POSITION ORGANIZATION
C.
PROVINCIAL, CITY OR UNIVERSITY LEVEL YEAR POSITION ORGANIZATION
D.
MUNICIPAL OR COLLEGE LEVEL YEAR POSITION ORGANIZATION
7. COMMUNITY / UNIVERSITY PROJECTS UNDERTAKEN (Attach documents/certifications)
List projects you have undertaken and classify them under national / regional / provincial and school levels.
A.
NATIONAL LEVEL NAME OF PROJECT COVERAGE AREA/ BENEFICIARIES
YEAR IMPLEMENTED
B. REGIONAL LEVEL YEAR IMPLEMENTED NAME OF PROJECT COVERAGE AREA/ BENEFICIARIES
C.
PROVINCIAL, CITY OR UNIVERSITY LEVEL NAME OF PROJECT COVERAGE AREA/ BENEFICIARIES
YEAR IMPLEMENTED
D.
MUNICIPAL OR COLLEGE LEVEL NAME OF PROJECT COVERAGE AREA/ BENEFICIARIES
YEAR IMPLEMENTED
To the best of my knowledge, the above facts as stated are true and correct. In addition, I declare that I am not a member of, or affiliated with, and will not support, any terrorist organization that seeks the violent overthrow of the duly constituted Government of the Republic of the Philippines.
___________________________ NAME AND SIGNATURE Date of Submission
