Region IV-A CALABARZON Employed with Department of Education NOTE:

Division QUEZON Lagyan ng fill up lahat ng red ang kulay

Last name Penduco Siguraduhin n tama ang fill up ng data (ito ay base s appointment, certificates etc)
First name Pedro Complete Name: PEDRO P. PENDUCO
MI P
Sex Male Name of PESS MARITA A. PIONILLA. Ed. D.
Mobile No 09985714670 Name of AO MARIA DOLORES D. ATIENZA
Date of Birth September13, 1980 Div Meet DSAC SHERWIN P. VARGAS
Age 38
Place of birth Burdeos, Quezon
School Cagbalete Island National High School
Employee No 006786
Current Position Teacher III
Years in service 17 years
School address Brgy. Cagbelete I Mauban, Quezon
Present address West Palale, Tayabas City
Please contact Gal Gadot
Contact number 09985714670
Bachelor of
Table B Secondary School Year graduated Credit Earned Awards received
Course College Education Southern Luzon Polytech 2001 Graduated Best in writing Kung walang award ay lagyan ng n/a
Post Graduate/masteral Master of Arts in Education Southern Luzon Polytech 2006 Graduated Most honest
Post Graduate/doctoral
Table C
Title of Sports training Date of training No. of hours Conducted by
Division training on sports Coaching June22-25 2018 24 DepEd Quezon
District training on sports Coaching September 13-15, 2017 24 DepEd Mauban South District

Table C
Athletic meet attended Inclusive dates Event Awards received
Congressional Meet Sepember 2-6, 2019 Dance Sports Gold
Division Meet November 2-6, 2019 Dance Sports
Cluster Meet December 2-6, 2019 Dance Sports
CALABARZON Heros Games Dance Sports
Palarong Pambansa Dance Sports

Coach Address West Palale Tayabas City

Present Position Teacher III
Start of Appointment June 17, 2002
August 2, 2019

CACR - 1 (COACH /ASST.COACH RECORD)

IV-A CALABARZON
Region

QUEZON
Division
Latest 1½ x 1½ picture

A. PERSONAL DATA:

Name: Penduco Pedro P

(Last) (First) (M.I.)

Sex: Male Mobile Phone Number: 09985714670

Date of Birth: (mm/dd/yy) September13, 1980 Age: 38 Place of Birth: Burdeos, Quezon

School: Cagbalete Island National High School Employee Number: 006786

Current Position: Teacher III Years in Service: 17 years
Address of School: Brgy. Cagbelete I Mauban, Quezon
Present Address: West Palale, Tayabas City
In Case of Emergency
Please Contact: Gal Gadot Contact Number: 09985714670

B. Educational Qualifications:
Course (College/Post
School Year Graduated Credits Earned Awards Received
Graduate)
Bachelor of Secondary Education Southern Luzon Polytechnic College 2001 Graduated Best in writing
Master of Arts in Education Southern Luzon Polytechnic College 2006 Graduated Most honest

C. Sports Training Attended for the last three (3) years

Title of Sports Training Date of Training No. of Hours Conducted by
Division training on sports Coaching June22-25 2018 24 DepEd Quezon
District training on sports Coaching September 13-15, 2017 24 DepEd Mauban South District

D. Sports Track Record/Experience

Athletic Meet Attended Inclusive Dates Event Awards Received
Congressional Meet Sepember 2-6, 2019 Dance Sports Gold
Division Meet Dance Sports
Cluster Meet Dance Sports
CALABARZON Heros Games Dance Sports
Palarong Pambansa Dance Sports

PEDRO P. PENDUCO
(Signature of Coach/Asst. Coach over Printed Name)

Prepared by: Attested by: Verified by:

PEDRO P. PENDUCO MARITA A. PIONILLA. Ed. D. MARIA DOLORES D. ATIENZA

(Coach /Asst. Coach Signature over Printed Name) (Division Sports Officer Signature over Printed Name) (Division AO/SDS Signature over Printed Name)

Screened by:

Division Meet Regional Meet Palarong Pambansa

SHERWIN P. VARGAS
(Signature of DSAC over Printed Name) (Signature of RSAC over Printed Name) (Signature of NSAC over Printed Name)

Date: ______________ Date: ______________ Date: ______________

FOR SCHOOL SPORTS (Division, Region, Palarong Pambansa)

NOTE:

Kailangan na tama ang fill up ng data

Sa mga events n hindi combative at gymnastics kailanagn n may 24 hrs

training for coaching ang coach bago cya ma allowed mgcoach at kung combative
at gymnastics ay 48 hrs n training for coaching ang kailangan

Kapag naselect ang coach sa higher meet ay susulatan n lang ang

inclusive dates ng table D. (kung masipag ang coach ay puede din itype)

Sa awards received s table D ay gold, silver, bronze o runner up ang ilalagay

Sa a4 po ito ipiprint

Iaatach n lang dito s form ang mga certificates ng sports seminars, at appoitment

Hindi n muna irerequired ang PDS s congressional at wala p update

tungkol dito
Republic of the Philippines)
City of ___________________)S.S.

OMNIBUS AFFIDAVIT
(for Public and Private Personnel)

I, PEDRO P. PENDUCO , of legal age, single/married,

with postal address at West Palale Tayabas City , after having duly
sworn in accordance with law hereby depose and state:

That I am presently employed with the Department of Education as

Teacher III ;

That I have been employed in Cagbalete Island National High School

since June 17, 2002 or for a period of 17 years ;

That I was designated as coach of Dance Sports , who

will participate in the School Sports activities of the Department of
Education up to 20___ Palarong Pambansa;

That all the athletes are not members of the National Team,
National Training Pool, and Development Pool whether or not receiving
monthly stipend/allowance from the Philippine Sports Commission
(PSC);

That all the athletes records submitted are true and correct to
the best of my personal knowledge;

That I execute this Affidavit to attest to the authenticity and

veracity of all the documents submitted.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______ day of _____________________20___ in ________________________,
Philippines.
PEDRO P. PENDUCO
Affiant

SUBSCRIBED and sworn to before me in ______________, this day

____________ of month 20___, affiant executing his/her _________________
___________, issued at _________ on _____________.

Notary Public

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

 Note:

Ito n ang gagamitin ng coach from public at private school

Kung nagpalipat lipat ng station ang coach, iattach n lang ay yung recent appointment nya
at dun n din itugma yung years of service/ period of service
Papipirmahan ito s abogado/ notary public

as Sa a4 po ito ipiprint
ppointment nya
 Republic of the Philippines
DEPARTMENT OF EDUCATION
IV-A CALABARZON
(Region)
QUEZON
(Division)
Cagbalete Island National High School
(School)
Brgy. Cagbelete I Mauban, Quezon
(School Address)

MEDICAL CERTIFICATE
(Coach, Asst. Coach, Chaperon)

To Whom It May Concern:

This is to certify that I have personally examined PEDRO P. PENDUCO

Name
age 38 sex Male and have found that he/she is Physically fit, during the time of

examination, to join and participate in the lower meets up to Palarong Pambansa.

Event: Dance Sports

Physical Examination
Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate

Provincial/Division/City Meet Remarks/Findings:

_______________________________
(Physician signature over printed name)
PRC License No. PTR No. Date Examined:

Regional Meet Remarks/Findings:

_______________________________
(Physician signature over printed name)
PRC License No. PTR No. Date Examined:

Palarong Pambansa Remarks/Findings:

_______________________________
(Physician signature over printed name)
PRC License No. PTR No. Date Examined:

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

NOTE:

Ito po ang gagamitin ng coach, assistant coach at chaperon

Siguraduhing tama ang fill up ng data

Dapat din po na my entry ang height, weight blood pressure, pulse rating

respiratory rate at remarks/ findings

ang pipirma po ay physician/ medical officer at huwag kalimutang ang license no/
PTR no. ng doctor at date examined

Ang space para s congressional meet ay dun s provincial/ division meet

Mgbabago n lang po ng medical kung maseselect ang coach s higher meet

dahil may posibilidad n mglapse and medical lalo n kung maagap ang mga congressional meet

From Lower meet to higher meet n ang form n ito gagamitin kya iwasan n mawala
Sa a4 po ito ipiprint