CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "

1. CS ID No.

" and use separate sheet if necessary.

T15157677

I. PERSONAL INFORMATION
ISIP

2. SURNAME
FIRST NAME

SHELLA MAE

MIDDLE NAME

MACASPAC

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

12/22/1993

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

5. PLACE OF BIRTH

16. RESIDENTIAL ADDRESS

MACABEBE, PAMPANGA
Male

6. SEX
7. CIVIL STATUS

# 514 SAN RAFAEL MACABEBE, PAMPANGA

Female

Single

Widowed

Married

Separated

Annulled

Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP

FILIPINO

9. HEIGHT (m)

1.59 m

ZIP CODE

2018
N/ A

17. TELEPHONE NO.

#514 SAN RAFAEL MACABEBE, PAMPANGA

10. WEIGHT (kg)

53 kg

11. BLOOD TYPE

B+

19. TELEPHONE NO.

N/ A

12. GSIS ID NO.

N/A

20. E-MAIL ADDRESS (if any)

maeisip@yahoo.com

13. PAG-IBIG ID NO.

N/A

21. CELLPHONE NO. (if any)

09755382165

14. PHILHEALTH NO.

N/A

22. AGENCY EMPLOYEE NO.

N/A

N/A

23. TIN

N/A

15. SSS NO.

ZIP CODE

2018

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME

N/A

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

FIRST NAME

N/A

N/A

DATE OF BIRTH (mm/dd/yyyy)

N/A

MIDDLE NAME

N/A

N/A

N/A

OCCUPATION

N/A

N/A

N/A

EMPLOYER/BUS. NAME

N/A

N/A

N/A

BUSINESS ADDRESS

N/A

N/A

N/A

TELEPHONE NO.

N/A

N/A

N/A

(Continue on separate sheet if necessary)

ISIP

FIRST NAME

ALEX

MIDDLE NAME

PAULE

26. FATHER'S SURNAME

27. MOTHER'S MAIDEN NAME

SURNAME

MACASPAC

FIRST NAME

STELLA

MIDDLE NAME

PILAO

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

INCLUSIVE DATES OF
ATTENDANCE

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

DEGREE COURSE
(Write in full)

full)

(if graduated)

From

To

ELEMENTARY

MACABEBE ELEMENTARY SCHOOL

GRADUATE

2006

2000

2006

SECONDARY
VOCATIONAL /

STA.MARIA HIGH SCHOOL

GRADUATE

2010

2006

2010

BULACAN STATE UNIVERSITY

BACHELOR OF
SCIENCE IN
SECONDARY
EDUCATION
MAJOR IN T.L.E

2015

2011

2015

COLLEGE
COURSE

TRADE

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

LICENSURE EXAMINATIONS FOR

TEACHERS

RATING

75.00%

DATE OF
EXAMINATION /
CONFERMENT

03/20/2016

LICENSE (if applicable)

PLACE OF EXAMINATION / CONFERMENT

UNIVERSITY OF THE EAST

NUMBER

1464744

DATE OF
RELEASE

06/17/201
6

(Continue on separate sheet if necessary)

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

INCLUSIVE DATES
(mm/dd/yyyy)
From

To

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

(Write in full)

GOV'T
SERVICE
MONTHLY
SALARY

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

STATUS OF
APPOINTMENT
(Yes / No)

(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)

N/A
N/A
N/A
N/A
N/A

NUMBER OF
HOURS

POSITION / NATURE OF WORK

From

To

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

(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

OUTCOMES BASED EDUCATION TOWARDS QUALITY

EDUCATION

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

To

11/11/2014

11/13/2014

24

BULACAN STATE UNIVERSITY

COLLEGE OF EDUCATION

ORIENTATION- SEMINAR ON EXPERIENTIAL LEARNING/ FIELD

07/05/2013
STUDY COURSES.

07/05/1013

BULACAN STATE UNIVERSITY

COLLEGE OF EDUCATION

(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)
SOCIETY OF TECHNOLOGY
AND
LIVELIHOOD EDUCATION
STUDENTS

READING
COMPUTER LITERATE
COOKING
DRESSMAKING

(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:

________________________________
________________________________

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

ADDRESS

TEL. NO.

MRS. ADELAIDA Q. FLORES

STA. MARIA MACABEBE, PAMPANGA

9267220721

MRS. JANNETTE BONIFACIO

STA. MARIA MACABEBE, PAMPANGA

9273788279

43.

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

06878905
COMMUNITY TAX CERTIFICATE NO.

MACABEBE, PAMPANGA
ISSUED AT

01/06/2016
ISSUED ON (mm/dd/yyyy)

SIGNATURE (Sign inside the box)

08/01/2016
DATE ACCOMPLISHED

RIGHT THUMBMARK

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