ETEEAP Application From CLSU

CONTROL NO.
_______
CLSU ETEEAP FORM 3
Republic of the Philippines

CENTRAL LUZON STATE UNIVERSITY
Science City of Muoz
3120 Nueva Ecija
Expanded Tertiary Education Equivalency and Accreditation Program (ETEEAP)
ETEEAP APPLICATION FORM
INSTRUCTION
2x2
ID Picture
Please type or clearly print your answers to all questions. Provide complete and detailed
information required by the questions. All the declarations that you make are under oath. Discovery
of any false claim in this application form will disqualify you from participating in the program.
I. PERSONAL INFORMATION
1. Name
(Last Name,
First Name,
Middle Name)
2. Address:
Zip Code:
3. Telephone No(s)/ eMAIL Address:
4. Birthdate:
5. Birthplace:
6. Civil Status:
7. Sex:
8. Languages and Dialects Spoken:
9. Degree Program or field being applied for:
First Priority:
Second Priority:
Third Priority:
10. Statement of your goals, objectives, or purposes in applying for the degree.
11. Indicate how much time you plan to devote for personal learning activities so that you can finish
the requirements in the prescribed program. Be specific.
12. For overseas applicants, describe how much you plan to obtain accreditation/equivalency. (e.g.
when you plan to come to the Philippines.)
13. How soon do you need to complete equivalent/accreditation?

less than one (1) year
1 year
2 years
3 years
4 years
more than 5 years
II. EDUCATION:
This section will require you to provide information on your past formal, non-formal and
informal learning experiences.
1. Formal Education
Course/Degree Program
Name of School/Address
Inclusive Dates of Attendance
Note: All entries should be supported by authenticated photocopy of appropriate certificates/diploma

obtained from the institution through the program.
2. Non-Formal Education
Non-formal education refers to structured and short-term training programs conducted for
particular purpose such as skills development, values orientation and the like.
Title of Training Program
Title of Certificate Obtained
Inclusive Dates of Attendance

3. Other Certification Examination
Please give detailed information on certification examinations taken for vocational and other
skills.
Title of Certification
Examination
Name/Address
of Certifying Agency
Date Certified
Rating

III. PAID WORK AND OTHER EXPERIENCES
1. Post/Designation
2. Inclusive Dates of Employment
From:
to
3. Name and Address of Company
4. Terms/Status of Employment
5. Name and Designation of Immediate Supervisor
6. Reason(s) for moving on to the next job
7. Describe actual functions and responsibilities in position occupied.
8. In case of self-employment, name three (3) reference persons:
Note: Use another sheet if necessary, following the above format.

IV. HONORS, AWARDS, AND CITATIONS RECEIVED
In this section, please describe all the awards you have received from schools, community and
civic organizations, as well as citations for work excellence, outstanding accomplishments, community
service, etc.
1. Academic Award
Awards Conferred
Name and Address of Conferring Organizations
Date Awarded
2. Community and Civic Organization Award/Citation

Awards Conferred
Date Awarded
3. Work Related Award/Citation

Awards Conferred
Date Awarded
V. CREATIVE WORKS AND SPECIAL ACCOMPLISHMENTS

In this section, enumerate the various creative works you have accomplished and other
special accomplishments. Examples of these are inventions, published and unpublished literary fiction
and nonfiction writings, musical work, products of visual performing arts, exceptional
accomplishments in sports, social, cultural and leisure activities, etc. which can lead one to conclude
the level of expertise you have obtained on certain field of interest. Include also participation in
competitions and prizes obtained.
1. Description:
2. Date Accomplished:
3. Name and Address of Publishing Agency (if written, published work), or an
Association/institution which can attest to the quality of the work.
Note: Use additional sheet if necessary, following the same format.

VI. LIFELONG LEARNING EXPERIENCE
In this section, please indicate the various life experiences from which you must have derived
some learning experiences. Please include here unpaid volunteer work.
1. Hobbies/Leisure Activities
Leisure activities which involve rating skills for competition and other purposes (e.g. belt
concept in Taekwondo) may also indicate your level for ease in evaluation. On the other hand,
watching Negosiyete on a regular basis can be considered a learning opportunity.
2. Special Skills
Note down those special skills which you think must be related to the fiels of study you want to
pursue.
3. Work-Related Activities
Some work-related activities are occasions for you to learn something new. For example,
being assigned to projects beyond your usual job description where you learned new skills and
knowledge. Please do not include formal training programs you already cited. However, you may
include here experiences which can be classified as on-the-job training or apprenticeship.
4. Volunteer Activities
List only volunteer activities that demonstrate learning opportunities, and are related to the
course you are applying for credit. (e.g. counseling programs, sports coaching, project organizing or
coordination, organizational leadership, and the like).
5. Travels: Cite places visited and purpose of travel

Include write-up of the nature of travel undertaken, whether for leisure, employment, business
or other purposes. State in clear terms what new learning experiences was obtained from theses
travels and how it helped you become a better person.
VI. To sum up, please write an essay on how your attaining a degree contribute to your personal
development, your community, your workplace, society, and country.
I declare under oath that, the foregoing claims and information u have disclosed are true and
correct. Done in_________________________________________________on this _____________
day of _______________________________________________________.
Signed:
Printed Name and Signature of Applicant
Community Tax Certificate

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CONTROL NO.

Republic of the Philippines

Expanded Tertiary Education Equivalency and Accreditation Program (ETEEAP)

ETEEAP APPLICATION FORM

13. How soon do you need to complete equivalent/accreditation?

Inclusive Dates of Attendance

Note: All entries should be supported by authenticated photocopy of appropriate certificates/diploma

Title of Certificate Obtained

Inclusive Dates of Attendance

Note: All entries should be supported by authenticated photocopy of appropriate certificates/diploma

Note: All entries should be supported by authenticated photocopy of appropriate certificates/diploma

3. Name and Address of Company

7. Describe actual functions and responsibilities in position occupied.

8. In case of self-employment, name three (3) reference persons:

Note: Use another sheet if necessary, following the above format.

Name and Address of Conferring Organizations

2. Community and Civic Organization Award/Citation

Name and Address of Conferring Organizations

3. Work Related Award/Citation

Name and Address of Conferring Organizations

V. CREATIVE WORKS AND SPECIAL ACCOMPLISHMENTS

Note: Use additional sheet if necessary, following the same format.

5. Travels: Cite places visited and purpose of travel

Printed Name and Signature of Applicant

Community Tax Certificate

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