Department of Social Welfare and Development

GOVERNMENT INTERNSHIP PROGRAM (GIP) & IMMERSION OUTREACH PROGRAM (IOP)

APPLICATION FORM

1 Name : ___________________________________________________________________________
(Surname) (First Name) (Middle Name)
2 Address : _________________________________________________________________________
3 Telephone : _________________________ 4 Mobile No. : _____________________
5 Date of Birth : ________________________ 6 Age : _____________
7 Place of Birth: _____________________________________________________________________
8 Highest Educational Attainment (fill out only the level of your last school atendance) :

NAME OF SCHOOL DEGREE/ EDUCATIONAL

COURSE YEAR STATUS INCLUSIVE DATES:
LEVEL & ADDRESS (Write in LEVEL (In-School/ Out-of
(Write in full) full) School)
From To
Secondary /
High School
Vocational/
Technical

College
9 Name and Occupation of parents:
Father : ________________________________ Occupation : ____________________
Mother : _______________________________ Occupation : ____________________
10 Family Composition (include relatives staying in the household and househelpers)

EDUCT'L OCCUPATION
CIVIL RELATION STATUS (include other NET
NAME AGE STATUS SHIP (In- sources of income/ INCOME
School/ support)
OSY)

10

11

12

13

14

15
TOTAL FAMILY INCOME

Note: Please include monthly pension, financial assistance from other relatives not living with the
family and others.
NOT FOR SALE
11 Work related skills: Please check
a. Clerical Works: Record filing ____ Operation of Office Equipment ____
Computer Literacy _____
b. Computer Operation (encoding): Word ____ Excel ____
PowerPoint _____
c. Technical Job Skills: Technical Writing ____ Convening/ Facilitating a Meeting ____
(Specify) _____________________________ Other _____________________________
12 Are you related by consanguinity of affinity to any DSWD officials or employees? Yes _____ No _____
If yes, give details ________________________________________________________________________

13 Character References :
NAME ADDRESS/ CONTACT NO. RELATIONSHIP

a.

b.

c.

14 List skills/ interest/ hobbies: ________________________________________________________________

15
Other Family Information: Very briefly, say something about your present family situation/ life/ difficulties or
explain why we have to choose or prioritize you from among GIP/ IOP applicants. (You may write it in Tagalog)

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

I certify that the above information is a true and complete statement and I authorize the DSWD to verify/
validate the contents stated herein. I trust that this information shall remain confidential.

________________________________
Signature of Intern

________________________________ ________________________________
Date Printed Name of intern
Attachements:
______ Photo/ Xerox copy of Birth Certificate of Government Issued ID
______ Most recent (school year/ Semester) school registration form or certification form the school
indicating the recent year/ semester of the applicant's school attendance.
______ Photocopy of income tax return (ITR) of parents/ head of the family/ guardian or Barangay
Certificate of Indigency confirming that family is residing in the barangay, with information on the total
monthly income (from all sources).

Contact #: 931-8101 local 407-410

Email Address: psb@dswd.gov.ph

NOT FOR SALE

 Republic of the Philippines
DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT
Caraga Field Office

Government Internship Program/ Immersion Outreach Program

WEEKLY ACCOMPLISHMENT REPORT

Province : _______________________________________
Municipality/ City : _______________________________________
Program/ Work Assignment: _______________________________________
Location/ Barangay : _______________________________________
Name of Supervisor : _______________________________________

Period Covered : _______________________________________

Signed By:
DATE ACTIVITIES/ ACCOMPLISHMENT
SUPERVISIOR

Submitted by: Noted by:

_____________________ ______________________
Printed name & signature of GIP/IOP Supervisor (C/MSWDO)

Approved by:

_________________________________
OIC-Chief/ Protective Services Division