CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "

1. CS ID No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
G| A | O| R |

2. SURNAME

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FIRST NAME

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MIDDLE NAME

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Orani, Bataan
Male

6. SEX
7. CIVIL STATUS

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| 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS

02/21/1994

4. DATE OF BIRTH (mm/dd/yyyy)

5. PLACE OF BIRTH

#345 Kawayan, Tugatog, Orani, Bataan

Female

Single

Widowed

Married

Separated

Annulled

Others, specify ___________ 18. PERMANENT ADDRESS

ZIP CODE

2112
N/A

17. TELEPHONE NO.

8. CITIZENSHIP

Filipino

#345 Kawayan, Tugatog, Orani, Bataan

9. HEIGHT (ft)

5'4

10. WEIGHT (kg)

48

11. BLOOD TYPE

"O"

19. TELEPHONE NO.

N/A

12. GSIS ID NO.

N/A

20. E-MAIL ADDRESS (if any)

gzenmark@yahoo.com

13. PAG-IBIG ID NO.

N/A

21. CELLPHONE NO. (if any)

09075819505

14. PHILHEALTH NO.

N/A

22. AGENCY EMPLOYEE NO.

N/A

15. SSS NO.

N/A

23. TIN

N/A

ZIP CODE

2112

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME

25. NAME OF CHILD (Write full name and list all)

N/A

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

N/A

MIDDLE NAME

N/A

OCCUPATION

N/A

EMPLOYER/BUS. NAME

N/A

BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

Gaor

FIRST NAME

Marianito

MIDDLE NAME

Soliva

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME

27. MOTHER'S MAIDEN NAME

SURNAME

Tolentino

FIRST NAME

Zenaida

MIDDLE NAME

Isidro

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.

YEAR
GRADUATED

NAME OF SCHOOL
(Write in

LEVEL

HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)

DEGREE COURSE
(Write in full)

full)
ELEMENTARY

Orani North Elementary School

SECONDARY
VOCATIONAL /

Orani National l High School

COLLEGE
COURSE

TRADE

Bataan Peninsula State University

(Orani, Campus)

From

To

2007

2001

2007

2011

2007

2011

2014

2012

(if graduated)

Associate in
Computer
Technology

INCLUSIVE DATES OF
ATTENDANCE

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29.

CAREER SERVICE/ RA 1080 (BOARD/ BAR)

UNDER SPECIAL LAWS/ CES/ CSEE

RATING

DATE OF
EXAMINATION /
CONFERMENT

LICENSE (if applicable)

PLACE OF EXAMINATION / CONFERMENT

Presidential Decree # 907

Licensure Examination for Teachers (LET)

77.40%

10/04/2009

Angeles City, Pampanga

NUMBER

DATE OF
RELEASE

10030141

March, 27,
2009

1039606

December
04, 2009

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.

INCLUSIVE DATES
(mm/dd/yyyy)
From

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

To

(Write in full)

GOV'T
SERVICE
MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT
(Yes / No)

5 /15 /13

Present

Teacher I

DEPED - Jose C. Payumo Jr. MHS

Php 18,549

Permanent

11/05/12

3 /22 /13

Teacher I

DEPED - Pagalangang National High

School

Php 10,933

JO

Yes

06/01/09

3 /31 /12

Instructor

College of Subic Montessori

Php 8,041

Contractual

No

Yes

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

31. NAME & ADDRESS OF ORGANIZATION

INCLUSIVE DATES
(Write in full)

(mm/dd/yyyy)
From

N/A

NUMBER OF
HOURS

POSITION / NATURE OF WORK

N/A

N/A

To

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training.)

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)

(mm/dd/yyyy)
From

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

To

Division Training Workshop on Robotics for Secondary Schools for

ICT, ENGLISH, MATH and SCIENCE Teachers

10/21/14

10/21/14

DEPED - Bataan

Division Sports Clinic in Coaching

09/11/14

09/13/14

24

DEPED - Bataan

Regional Mass Training for Grade 9 Teachers

05/15/14

05/19/14

54

DEPED - Bataan

Division Sports Clinic in Coaching

07/18/13

07/20/13

24

DEPED - Bataan

Division Teacher Induction Program (TIP) for Beginning Teachers in

Public Schools

07/11/13

07/12/13

16

DEPED - Bataan

Division Training for Untrained Grade 8 Teachers and Department

Heads on the Implementation of K to 12 Curriculum

06/13/13

06/14/13

16

DEPED - Bataan

Regional Mass Training for Grade 8 Teachers

05/06/13

05/10/13

54

DEPED - Bataan

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

33.

SPECIAL SKILLS / HOBBIES:

34.

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

(Write in full)

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)

Driving

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4

36.

Are you related by consanguinity or affinity to any of the following :

a.

Within the third degree (for National Government Employees):

appointing authority, recommending authority, chief of office/bureau/department or person who
has immediate supervision over you in the Office, Bureau or Department where you will be
appointed?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

b.

Within the fourth degree (for Local Government Employees):

appointing authority or recommending authority where you will be appointed?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37

a. Have you ever been formally charged?

YES

NO

If YES, give details:

________________________________
________________________________
YES

b. Have you ever been guilty of any administrative offense?

NO

If YES, give details:

________________________________
________________________________
38.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?

39.

Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
phased out, in the public or private sector?

40.

YES
NO
If YES, give details:
________________________________
________________________________
YES

NO

If YES, give details:

Resigned_from private to public
school.

Have you ever been a candidate in a national or local election (except Barangay election)?

YES

NO

If YES, give details:

________________________________
________________________________
41.

Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA
7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following items:

a.

Are you a member of any indigenous group?

b.

Are you differently abled?

c.

Are you a solo parent?

YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME

43.

ADDRESS

TEL. NO.

Roy M. Vicarme

Dalao Dinalupihan Bataan

N/A

Eugenio S. Magno

New San Jose Dinalupihan Bataan

9204019474

I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.

ID picture taken within

the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4