CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "

T15169878

1. CS ID
No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
LOPEZ

2. SURNAME
FIRST NAME

CHRISTHOTEL

MIDDLE NAME

CASABON

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

10 / 18 / 1997

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

16. RESIDENTIAL ADDRESS

Quezon City

5. PLACE OF BIRTH

MALE

6. SEX

FEMALE

7. CIVIL STATUS

Single

Widowed

Married

Separated

Annuled

Others, specify
_________

8. CITIZENDSHIP

Filipino

9. HEIGHT (m)

170

10. WEIGHT (kg)

65

11. BLOOD TYPE

O+

3481 Honda Street, CITY OF MAKATI, NCR FOURTH

DISTRICT

ZIP CODE

1213

17. TELEPHONE NO.

8817635

18. PERMANENT ADDRESS

3481 Honda Street, , NCR FOURTH DISTRICT

ZIP CODE

1213

19. TELEPHONE NO.

8817635

12. GSIS ID NO.

20. EMAIL ADDRESS (if any)

thotel1018@gmail.com

13. PAGIBIG ID NO.

21. CELLPHONE NO. (if any)

09956239881

14. PHILHEALTH NO.

0202-6441-7261

22. AGENCY EMPLOYEE NO.

15. SSS NO.

34-3879536-6

23. TIN

436-825-360

II. FAMILY BACKGROUND

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

24. SPOUSE'S SURNAME

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME

LOPEZ

FIRST NAME

HECTOR

MIDDLE NAME

BRAVA

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME

CASABON

FIRST NAME

CECILIA

MIDDLE NAME

AGUI

III. EDUCATIONAL BACKGROUND

LEVEL

NAME OF SCHOOL
(Write in full)

ELEMENTARY

NEMESIO I. YABUT
ELEMENTARY SHOOL

SECONDARY

MAKATI HIGH SCHOOL

DEGREE COURSE
(Write in full)

YEAR
GRADUATED
(if graduated)

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

From

To

2000-0605

2006-0408

2006-0605

2008-0407

2010

2008-0602

2010-0328

2015

2011-0606

2015-0408

2006

PITOGO HIGH SCHOOL

INCLUSIVE DATES OF
ATTENDANCE

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

VOCATIONAL/ TRADE
COURSE

COLLEGE

PHILIPPINE NORMAL
UNIVERSITY

LOPEZ, CHRISTHOTEL CASABON - T15169878

BACHELOR OF
SECONDARY
EDUCATION

N/A

CS FORM 212 (Revised 2005), Page 1 of 3

III. EDUCATIONAL BACKGROUND

LEVEL

NAME OF SCHOOL
(Write in full)

DEGREE COURSE
(Write in full)

MASTER OF ARTS IN
SCIENCE
EDUCATION

PHILIPPINE NORMAL
UNIVERSITY

GRADUATE STUDIES

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

YEAR
GRADUATED
(if graduated)

INCLUSIVE DATES OF
ATTENDANCE

From

To

2016-0411

Present

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

IV. CIVIL SERVICE ELIGIBILITY

29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
UNDER SPECIAL LAWS/ CES/ CSEE

RATING

LET (LICENSURE EXAMINATION FOR

TEACHER)

LICENSE (if applicable)

DATE OF
EXAMINATION /
CONFERMENT

78.60

09 / 27 / 2015

PLACE OF EXAMINATION / CONFERMENT

NUMBER

Manila

1414874

DATE OF
RELEASE

11/30/2015

V. WORK EXPERIENCE
30.

INCLUSIVE DATES
(mm/dd/yyyy)
From

To

06/01/2015

04/17/2017

POSITION TITLE (Write in full)

DEPARTMENT / AGENCY / OFFICE /

COMPANY (Write in full)

MONTHLY
SALARY

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

STATUS OF
APPOINTMENT

GOV'T SERVICE
(Yes / No)

Instructor

Philippine State College of

Aeronautics

18333.33

12 - 1

Contract of
Service

Yes

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

31.

INCLUSIVE DATES
(mm/dd/yyyy)

NAME & ADDRESS OF ORGANIZATION

(Write in full)

From

To

NUMBER OF
HOURS

POSITION / NATURE OF WORK

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

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

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

INCLUSIVE DATES OF
ATTENDANCE
(mm/dd/yyyy)
From

To

2016 INTERNATIONAL HIGHER EDUCATION RESEARCH FORUM

09 / 14 / 2016

09 / 17 / 2017

30

PHILIPPINE HIGHER
EDUCATION RESEARCH
CONSORTIUM

NATIONAL IMPLEMENTATION OF SENIOR HIGH SCHOOL (SHS)

TEACHER TRAINING FOR LOCAL UNIVERSITIES AND COLLEGES AND
STATE UNIVERSITIES AND COLLEGES

05 / 24 / 2016

05 / 27 / 2017

30

COMMISSION ON HIGHER
EDUCATION

ILAS MIDYEAR PEDAGOGICAL WORKSHOP

10 / 29 / 2015

10 / 31 / 2015

16

PHILIPPINE STATE COLLEGE

OF AERONAUTICS

CAPACITY-BUILIDING SEMINAR FOR PRE-SERVICE TEACHERS:

GETTING READY K TO 12 CURRICULUM

03 / 09 / 2015

03 / 12 / 2015

12

PHILIPPINE NORMAL
UNIVERSITY

ZERO WASTE YOUTH CONVERGENCE

01 / 07 / 2015

01 / 27 / 2014

MOTHER EARTH FOUNDATION

FUNDAMENTAL NATURE OF THE UNIVERSE

11 / 26 / 2014

11 / 26 / 2014

K-12 (EBEC) PROGRAM ON CURRICULUM AND ASSESSMENT

03 / 11 / 2013

03 / 11 / 2013

PHILIPPINE NORMAL
UNIVERSITY

VIII. OTHER INFORMATION

33.

SPECIAL SKILLS / HOBBIES:

34.

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

(Write in full)

35. MEMBERSHIP IN ASSOCIATION / ORGANIZATION

(Write in full)

Proficient in Computer Softwares

Philippine Normal University - Astronomical

Society

Good in Statistics

Philippine Normal University - Science and

Technology Club

Research

LOPEZ, CHRISTHOTEL CASABON - T15169878

CS FORM 212 (Revised 2005), Page 2 of 3

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?

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:

_____________________________________
_____________________________________
_____________________________________

YES

NO

If YES, give details:

_____________________________________
_____________________________________
_____________________________________

37. a. Have you ever been formally charged?

YES

NO

If YES, give details:

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

YES

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?

YES

NO

If YES, give details:

_____________________________________
_____________________________________
YES

NO

If YES, give details:

FINISHED CONTRACT

40. 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?

YES

NO

If YES, please specify:_______________________

b. Are you differently abled?

YES

NO

If YES, please specify:_______________________

c. Are you a solo parent?

YES

NO

If YES, please specify:_______________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME
LIGAYA CAYA
DR. RODANTE G. FLORES
DR. VIRGIL DUAD

ADDRESS
PHILIPPINE STATE COLLEGE OF
AERONAUTICS
PHILIPPINE STATE COLLEGE OF
AERONAUTICS
PHILIPPINE NORMAL UNIVERISTY

TEL. NO.
09176201054
09258772633
09059126535

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.

X
PHOTO

25003896
COMMUNITY TAX CERTIFICATE NO.
Makati City
ISSUED AT

SIGNATURE (Sign inside the box)

2017-01-13

01 / 13 / 2017

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

LOPEZ, CHRISTHOTEL CASABON - T15169878

RIGHT THUMBMARK

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