CS Form No.

1
Revised 2018
For Use of Regulated Agencies Only
APPOINTMENT TRANSMITTAL AND ACTION FORM

AGENCY:
AGENCY : LOCAL GOVERNMENT UNIT-BACACAY CSC FO In-Charge:

INSTRUCTIONS: For CSC RO/FO's Use:

(1) Fill-out the data needed in the form completely and accurately. Date Received:
(2) Do not abbreviate entries in the form. SALARY/
JOB/
(3) Accomplish the Checklist of Common Requirements and sign the certification.
A - Approved
(4) Submit the duly accomplished form in electronic and printed copy (2 copies) to the CSC Field Office-In-Charge
together with the original copies of appointments and supporting documents.
POSITION TITLE

NAME OF THE APPOINTEE/S PUBLICATION CSC ACTION

or
PERIOD OF EMPLOYMENT
DATE OF DATE MODE Agency
Name EMPLOYMENT NATURE OF indicate period (CSC Bulletin of Date of
(for Temporary, Casual/ ISSUANCE Date of Action Receiving
Last Name First Name Extension Middle Name STATUS APPOINTMENT of publication Vacant Positions, Release
Contractual Appointments) (mm/dd/yyyy) (mm/dd/yyyy) Officer
(Jr. / III) (mm/dd/yyyy to mm/dd/yyyy) (mm/dd/yyyy to Agency Website, (mm/dd/yyyy)
mm/dd/yyyy) Newspaper, etc)
No. (indicate
parenthetical title, if
1 AMPONGAN JINKY BELLEN Administrative Aide I
applicable) Gr. 1 Casual 7/1/2020-12/31/2020 ORIGINAL 7/1/2020
2 BASMAYOR NOREEN BENDAÑA Administrative Aide I Gr. 1 Casual 7/1/2020-12/31/2020 ORIGINAL 7/1/2020
D-
3 BANDOLA LUIS AÑONUEVO Administrative Aide I Gr. 1 Casual 7/1/2020-12/31/2021 ORIGINAL 7/1/2020 Disapproved or
4 YUMUL ROQUELITO BARCENAS Administrative Aide I Gr. 1 Casual 7/1/2020-12/31/2021 ORIGINAL 7/1/2020 N-
PAY Noted
4 BENDAÑA DEXTER RIOSA Administrative Aide I Gr. 1
GRADE Casual 7/1/2020-12/31/2021 ORIGINAL 7/1/2020
5
6
7
8
9
10
11
12
13
14
15

CERTIFICATION

This is to certify that the information contained in this form are true, correct and complete.

RICHARD B. BEJER
OIC-HRMO

Date: _________________________________

REMARKS/COMMENTS/RECOMMENDATIONS: (e.g. Reasons for Disapproval of Appointment)

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 CHECKLIST OF COMMON REQUIREMENTS HRMO CSC FO
Instructions: Put a check if the requirements are complete. If incomplete, use the space provided to indicate the name of appointee and the lacking requirement/s.

APPOINTMENT FORMS (CS Form No. 33-A, Revised 2018) - Three (3) original
1 copies of appointment form (employee copy, CSC copy and agency copy)

PLANTILLA OF CASUAL APPOINTMENT (CSC Form No. 34-A, C, E or F) - Three

2 (3) original copies (employee copy, CSC copy and agency copy)

3 PERSONAL DATA SHEET (CS Form No. 212, Revised 2017)

ORIGINAL COPY OF AUTHENTICATED CERTIFICATE OF ELIGIBILITY/ RATING/

4 LICENSE - Except if the eligibility has been previously authenticated in 2004 or
onward and recorded by the CSC

5 POSITION DESCRIPTION FORM (DBM-CSC Form No. 1, Revised 2017)

6 OATH OF OFFICE (CS Form No. 32, Revised 2017)

7 CERTIFICATE OF ASSUMPTION TO DUTY (CS Form No. 4)

This is to certify that I have checked the veracity, This is to certify that I have checked all the
authenticity and completeness of all the requirements in requirements in support of the appointments attached
support of the appointments attached herein. herein and found these to be [ ] complete / [ ] lacking.

____________________________________ ____________________________________
HRMO CSC FO Receiving Officer
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