DEPARTMENT OF EDUCATION
Region X – Northern Mindanao
DIVISION OF BUKIDNON
APPLICATION FORM FOR TRANSFER OF TEACHING ASSIGNMENT
TEACHER PROFILE (To be filled up by the teacher applying for transfer.)
Name
Last Name First Name Middle Name
Home Address
Purok/Sitio Barangay Municipality Province
Current Station Name of School District
Current Station Address
Barangay Municipality Province
Number of Years in Current Station Position
First Day of Service in Current Station SG/Step
CB PAST Rating
SY 2014-15 SY 2013-14 SY 2012-13
SCHOOL APPLIED FOR TRANSFER (To be filled up by the teacher applying for transfer)
Preference 1 School District
Address
Purok/Sitio Barangay Municipality Province
Preference 2 School District
Address
Purok/Sitio Barangay Municipality Province
Preference 3 School District
Address
Purok/Sitio Barangay Municipality Province
ENROLMENT PROFILE
A. CLASS ENROLMENT (To be filled up by the teacher applying for transfer. Fill up the appropriate class
type only)
Enrolment No. of Years
Class Type Grade Handling this
Male Female Total
Type of Class
Solid Class
Combination
Class
Multigrade
Class
B. SCHOOL ENROLMENT (To be filled up by the teacher or the school head. Enter the appropriate
information relative to the current school type (i.e. Elementary, Secondary)
ENROLMENT
SY 2010- SY 2011- SY 2012- SY 2013- SY 2014-
GRADE
2011 2012 2013 2014 2015
REMARKS
M F M F M F M F M F
TOTAL
REASONS FOR APPLICATION OF TRANSFER
Check the appropriate box(es) and attach the required document as indicated therein.
Excess teacher (Attach Certification of School Head)
Has served for five (5) or more years in current station outside of home barangay or
municipality (Attach Certification of School Head)
Bonafide resident of barangay where the school applied for is located (Attach COMELEC VRR
and Barangay Certificate)
Joining spouse in school applied for (attach Marriage Certificate and Certification of current
assignment
or station of spouse by the concerned school head) RA 4670
Nursing Mother (attach birth certificate of child) PD 603, Child and Youth Welfare Code
Life is in danger due to armed conflict, hostilities or other similar circumstances
(attach LGU Certification of Municipal/Barangay Peace and Order Situation or PNP Extract of Police
Blotter indicating the conflict or hostilities and other relevant information relative thereto)
Poor health condition (Attach Medical certificate by licensed/government doctor/medical officer
indicating
the recommendations that would warrant the transfer of station.
OMNIBUS SWORN STATEMENT
We, ___________________________________ and ___________________________________
Teacher School Head
Filipino, of legal age, with permanent address at _____________________________________
and ____________________________________, respectively, after having been sworn in
accordance with law, hereby depose and state that:
1. We understood the requirements for transfer as stipulated in DepED Order No. 22, s. 2013
or the Revised Guidelines in the Transfer of Teachers from One Station to Another;
2. All information we have caused to be entered in this form are true and correct to the best
of our knowledge;
3. We are aware that anyone found guilty of violating any of the provisions of the DepED
Order No. 22, s. or any part thereof shall be charged administratively pursuant to RA 6713
otherwise known as the Code of Conduct and Ethical Standards for Public Officials and
Employees and other relevant laws, rules and regulations;
In witness whereof, we hereby affix our signatures this ____ day of ________________, 2015 at
_________________________________________________________.
(Signature Over Printed Name of Teacher) (Signature Over Printed Name of School Head)
Position Position
ACKNOWLEDGEMENT
SWORN AND SUBSCRIBED before me this _____ day of ____________________ at
___________________________________________________.
