36.

Are you related by consanguinity to any of the following

a. Within the third degree (for National Government Employees) YES NO

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?
If YES, give details
___________________________________________________
___________________________________________________

YES NO
b. Within the fourth degree (for Local Government Employees): If YES, give details
appointing authority or recommending authority where you will
___________________________________________________
be appointed?
___________________________________________________

37. a. Have you ever been formally charged? YES NO

If YES, give details
__________________________________________________
__________________________________________________

YES NO
b. Have you ever been guilty of any administrative offense?
If YES, give details
__________________________________________________
__________________________________________________

38. Have you ever been convicted of any crime or violation of any law , decree,
YES NO
ordinance or regulation by any court of tribunal?
If YES, give details
__________________________________________________
__________________________________________________

39. Have you ever been separated from the service in any of the following modes,
YES NO
Resignation, retirement, dropped from the rolls, dismissal, termination, end of
term, If YES, give details
If finished contract, AWOL or phased out in the public or private sector? __________________________________________________
__________________________________________________

40. Have you ever been a candidate in a national or local election

YES NO
(Except Barangay Election)?
If YES, give details
__________________________________________________
__________________________________________________

41. Pursuant to: (a) Indigenous Peoples Act,(RA 8371) (b) Magna Cart for
Disabled Persons (RA 7277) and (c) Solo Parents Welfare Act of 2000 (RA
8972)
please answer the following items:

YES NO
a. Are you a member of any indigenous group? If YES, please specify. ____________________________

YES NO
b. Are you differently abled? If YES, please specify. ____________________________

YES NO

c. Are you a solo parent? If YES, please specify. ____________________________

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

NAME ADDRESS TEL. NO.
MYRNA D. OVILLO KALAMANSIG, SULTAN KUDARAT 09106856852 ID picture taken within
JAIME B. ANDRES Sr. BASAK, LEBAK, SULTAN KUDARAT The last 6 months
JONATHAN R. GORIEZA MLANG, NORTH COTABATO 3.5 cm. X 4.5 cm.
MELINDA M. MANDIADE KALAMANSIG, SULTAN KUDARAT 09203041137 (passport size)
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, Computer generated
correct and complete statement pursuant to the provisions of pertinent laws, rules and or Xerox copy of
regulations of picture is not
the Republic of the Philippines. acceptable

I also authorize the agency head /authorized representative to verify / validate the contents
stated
herein. I trust that this information shall remain confident.

21518487
COMMUNITY TAX CERTIFICATE NO

KALAMANSIG, SULTAN KUDARAT

ISSUED AT Signature (sign inside the box)

RIGHT THUMBMARK

01/10/2017 FEBRUARY 10, 2017

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED
 CS FORM 212 ( Revised 2005) Page 4 of 4

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

ORGANIZATIONS
INCLUSIVE DATES
31. NAME AND ADDRESS OF ORGANIZATION (mm/dd/yyyy) NUMBER OF CONDUCTED/ SPONSORED BY
(Write in full) From To HOURS (Write in full)

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
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) ATTENDANCE NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy) HOURS (Write in full)
From To
DIVISION TRAINING-WORKSHOP ON THE USE OF NEW
DLL/DLP 7/15/16 7/15/16 8 DIVISION

ECHO SEMINAR-WORKSHOP ON CAMPUS JOURNALISM / / / / 8 DISTRICT

DISTRICT ECHO SEMINAR-WORKSOP IN TEACHING FOR

GRADES I TO III 1/15/16 1/16/16 16 DISTRICT

SEMINAR WORKSHOP IN THESIS WRITING AND FORMATTING 6/21/14 06/23/14 24 SCHOOL

SEMINAR-WORKSHOP ON CAMPUS JOURNALISM/LAY-

SKSU-ACCESS
OUTING/EDITING

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
33. SPECIAL SKILLS / HOBBIES 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION 35. ASSOCIATION/ORGANIZATION
(Write in full) (Write in full)
TEACHING AWARDED AS AN ACTIVE TEACHER IN SCHOOLS CO-ADVISER OF ANG MANLALAYAG MAGAZINE
TECHNICAL/OFFICIATING OFFICIALS IN DUAL
PUBLIC SPEAKING MEMBER OF KALAMANSIG TEACHERS AND
MEET 2016
EMPLOYEES ASSOCIATION (KTEA)
COMPUTER LITERATE AWARDED AS AN BOY-SCOUT QUIZ COACH 2016
DUMMY MAKER
WRITER/COMPOSER 3RD HONORABLE MENTION 2011
OUTDOOR GAMER TOP TEN PUPILS 2001-2007
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005) Page 3 of 4
IV. CIVIL SERVICE ELIGIBILITY
DATE OF LICENSE (if applicable)
29. CAREER SERVICE/ RA 1080 (BOARD/ BAR)UNDER RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT DATE OF
SPECIAL LAWS/ CES/ CSEE NUMBE
CONFERMENT RELEASE
R

03-20-
LICENSURE EXAMINATION FOR TEACHERS 75% PAGADIAN CITY
16

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE GOVT
POSITION TITLE MONTHLY SALARY STATUS OF
DATES DEPARTMENT / AGENCY / OFFICE / COMPANY SERVIC
(Write in full) SALARY GRADE &
APPOINTMENT
(mm/dd/yyyy) (Write in full) STEP E
INCREMENT
from to (Formal *00-
(Yes /
0*) No)

/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005) Page 2 of 4

CS FORM 212 (Revised 2005)

 PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes with and use a separate sheet if 1. CS ID (to be filled up by CSC)
necessary. No.
I. PERSONAL INFORMATION
2. SURNAME C|A|S|T|R|O| | | | | | | | | | | | | | | | | | |

FIRST R|A|Y|A|N| | | | | | | | | | | | | | | | | | |
NAME
3. NAME EXTENSION (e. g.
MIDDLE L|A|U|R|E|A|N|O| | | | | | | Jr., Sr.
NAME
4. DATE OF BIRTH (mm/dd/yyyy) 10/14/1992 16. RESIDENTIAL
ADDRESS
5. PLACE OF PUROK PAG-ASA, STA. CLARA. KALAMANSIG,
BASAK, LEBAK, SULTAN KUDARAT
BIRTH SULTAN KUDARAT
6. SEX Male Female
7. CIVIL STATUS Single Widowed ZIP 9808
Married Separated CODE
N/A
Annulled Others, specify 17. TELEPHONE NO.
___________
18. PERMANENT
ADDRESS
8. CITIZENSHIP FILIPINO BASAK, LEBAK, SULTAN KUDART
9. HEIGHT (m)
10. WEIGHT (kg) 55 9807
ZIP
11. BLOOD TYPE +O
CODE N/A
19. TELEPHONE NO.
12. GSIS ID NO. 20. E-MAIL ADDRESS (if
berian_43@yahoo.com
any)
13. PAG-IBIG ID 21. CELL PHONE NO. (if
+639460129994
NO. any)
14. PHILHEALTH 22. AGENCY EMPLOYEE
NO. NO.
15. SSS NO. 23. TIN
II. FAMILY BACKGROUND
24. SPOUSES N/A 24. NAME OF CHILD (Write full name DATE OF BIRTH
SURNAME and list all) (mm/dd/yyyy)

FIRST N/A N/A /

NAME /
MIDDLE N/A /
NAME
/
OCCUPATION N/A /
/
EMPLOYER / BUS. N/A /
NAME /
BUSINESS ADDRESS N/A /
/
TELEPHONE NO. N/A /
/
(Continue on separate sheet if necessary) /
/
26. FATHERS NAME /
/
CASTRO
SURNAME

FIRST
PRUDENCIO /
NAME /
VENTURA /
MIDDLE NAME
/
27. MOTHERS MAIDEN NAME /
/
LAUREANO /
SURNAME /
MELANE /
/
FIRST NAME
PELITRO (Continue on separate sheet if necessary)

MIDDLE NAME

III. EDUCATIONAL BACKGROUND

28. DEGREE YEAR HIGHEST INCLUSIVE DATES OF SCHOLARSHIP/
 LEVEL NAME OF SCHOOL COURSE GRADUATE GRADE/ ATTENDANCE ACADEMIC
(Write in full) (Write in D LEVEL/ HONORS
From To
full) (If UNITS RECEIVED
graduated) EARNED
(If not
graduated)

ELEMENTARY F. PAROHINOG SR. MEMORIAL

ELEMENTARY SCHOOL

SECONDARY E. ARCAO MEMORIAL NATIONAL HIGH

SCHOOL

VOCATIONAL
/
TRADE
COURSE
SULTAN KUDARAT STATE UNIVERSITY- BSED
COLLEGE KALAMANSIG FILIPINO

GRADUATE
STUDIES

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005) Page 1 of 4