CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME T| U | G | A | G | A | O | | | | | | | | | | | | | | | | | | | | |

FIRST NAME T| I | R | S | O| | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME R| I | V | E | R| A | | | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.) N/A

4. DATE OF BIRTH (mm/dd/yyyy) 08/13/1980 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH Aparri, Cagayan Valley Zone 5, Barangay Gaddang, Aparri, Cagayan Valley
6. SEX Male Female
7. CIVIL STATUS 3515
Single Widowed ZIP CODE

Married Separated 17. TELEPHONE NO. 0925-5565-165

Annulled Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP Filipino Zone 5, Barangay Gaddang, Aparri, Cagayan Valley

9. HEIGHT (m) 1.609
10. WEIGHT (kg) 63 ZIP CODE 3515
11. BLOOD TYPE O 19. TELEPHONE NO. 0925-5565-165
12. GSIS ID NO. 02003462339 20. E-MAIL ADDRESS (if any) tirsotugagao@yahoo.com
13. PAG-IBIG ID NO. 1340-0028-8078 21. CELLPHONE NO. (if any) 0925-5565-165
14. PHILHEALTH NO. 06-000059853-7 22. AGENCY EMPLOYEE NO. 2595
15. SSS NO. 33-1699131-8 23. TIN 944-400-032-000
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME Raven Charl S Tugagao 05/09/2006

MIDDLE NAME / /
OCCUPATION / /
EMPLOYER/BUS. NAME / /
BUSINESS ADDRESS / /
TELEPHONE NO. / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME Tugagao 09/ 05 /1955
FIRST NAME Rodolfo / /
MIDDLE NAME Aytona / /
27. MOTHER'S MAIDEN NAME Rivera 01/ 22 /1958
SURNAME Tugagao / /
FIRST NAME Magdalena / /
MIDDLE NAME Lazza (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR

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

TALLUNGAN ELEMENTARY SCHOOL- (if graduated)

ELEMENTARY Elementary 1993 GRADUATE 1987 1993 GRADUATE
Aparri, Cagayan Valley
CAGAYAN STATE UNIVERSITY-Aparri,
SECONDARY High School 1997 GRADUATE 1993 1997 GRADUATE
Cagayan Valley

Electronic Data
2004
Processing (EDP)
CENTENNIAL COMPUTER &
VOCATIONAL/TRADE COURSE ELECTRONICS SCHOOL (CENSES
College)-Aparri, Cagayan Valley Computer
Programming 2009
(NCIV)
COLLEGE Bachelor in
STUDENT OF THE
CAGAYAN STATE UNIVERSITY-Aparri, Secondary
2001 GRADUATE 1997 2001 YEAR & SERVICE
Cagayan Valley Education Major in
AWARD
Mathematics
GRADUATE STUDIES
Master of Arts in
CAGAYAN STATE UNIVERSITY-Aparri,
Educational 2005 GRADUATE 2001 2005 GRADUATE
Cagayan Valley
Management
CAGAYAN STATE UNIVERSITY-Aparri, Doctor of
21 UNITS
Cagayan Valley Philosophy
Doctor of
LYCEUM OF APARRI-Aparri, Cagayan Valley 39 UNITS
Philosophy
(Continue on separate sheet if necessary)
Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE

Licensure Examination for Teachers (LET) 76.80% 08/26/2001 Tuguegarao City, Cagayan Valley 0714130 10/20/01

Computer Hardware Servicing NC II Competent 10/13/2014 TESDA-Aparri Polytechnic Institute 10/13/14

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
DepEd/Division of Cagayan/Aparri East Regular
06/07/2010 Present Secondary School Teacher III 21,436.00 13-01 Yes
National High School Permanent
/
Part Time Instructor of Physics &
10/01/2013 Present Cagayan State University at Aparri 2,000.00 Temporary Yes
Mathematics
/
Part Time Instructor of
10/01/2013 Present Mathematics & Education Lyceum of Aparri 1,500.00 Temporary No
/ Subjects
DepEd/Division of Cagayan/Aparri East Regular
01/08/2008 06/06/2010 Secondary School Teacher I 14,026.00 10-01 Yes
National High School Permanent
/
DepEd/Division of Cagayan/Aparri East
01/23/2006 01/07/2008 Provincial School Teacher 6,000.00 Volunteer Yes
National High School
/
System Administrator/Math, Centennial Computer & Electronics
01/22/2005 01/22/2006 6,000.00 Permanent No
Science, Computer Teacher School (CENSES College)
/
School Cashier/Math, Science, Centennial Computer & Electronics
01/21/2004 01/21/2005 6,000.00 Permanent No
Computer Teacher School (CENSES College)
/
Bookkeeper/Math, Science, Centennial Computer & Electronics
01/20/2003 01/20/2004 5,000.00 Permanent No
Computer Teacher School (CENSES College)
/
Property Custodian/Math, Centennial Computer & Electronics
01/19/2002 01/19/2003 5,000.00 Permanent No
Science, Computer Teacher School (CENSES College)
/
Activity Coordinator/Math, Centennial Computer & Electronics
06/04/2001 01/18/2002 4,500.00 Permanent No
Science, Computer Teacher School (CENSES College)
/
/ / / /

/ / / /

/ / / /

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/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

(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
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

PNP CIDG-Community Investigative Support (CIS) 01/10/2012 Present Secretary/Volunteer

1 Guardians Nationalist in the Philippines Incorporated (1GANAP) 08/13/2007 Present Chairman President/Volunteer

Citizens Community Defense Group (CCDF Forces 10/10/2010 Present Intelligence Officer/Volunteer

/ / / /

/ / / /

(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 NUMBER OF CONDUCTED/ SPONSORED BY
in full) (mm/dd/yyyy) HOURS (Write in full)
From To

Joint iSchools Project Close Out 03/01/2013 03/01/2013 24 DOST-ICT/Ifugao State University

PNP CIDG Camp Crame, Quezon

CIDG-CIS Trainor's Training Seminar 09/06/2012 09/07/2012 16
City

Website Development Training 08/08/2012 08/12/2012 40 DOST-ICT/Isabela State University

DepEd/Mathematics Teachers
First MTAP National Conference and Seminar Workshop in
04/25/2012 04/28/2012 32 Association of the Philippines, Inc
Mathematics
(MTAP)
DOST-ICT/Tarlac College of
Library Management Training 01/16/2012 01/20/2012 40
Agriculture

Laboratory Management Training 09/02/2011 09/04/2011 24 DOST-ICT/Isabela State University

Regional Strategic Intervention Materials (SIM) Development

01/25/2011 01/27/2011 24 DepEd/Regional Office No. 2
Seminar Workshop
DOST-ICT/Ilocos Sur Polytechnic
Sustainability Planning Workshop Roll-Out Training 11/22/2010 11/25/2010 32
State College
Maintain and Repair Cellular Phones Leading to Consumer
01/08/2010 01/23/2010 320 TESDA Region II
Elecgronics Servicing NC II

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(Write in full)
Mathematics Teachers Association of
Computer Technicial (Software & Hardware) Outstanding Secondary School Teacher 2014
the Philippines
Philippine Association for Teachers
Web Page Designer (Using Wordpress) Teacher of the Year 2005
Education
Criminal Investigation & Detection
Data Encoder, Computer Literate (MS Word, Excel,
Group (CIDG)-Community
Powerpoint, etc.)
Investigative Support (CIS)

Cellular Phone Technician

(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): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
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): YES NO

appointing authority or recommending authority where you will be appointed? 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 YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. Have you ever been separated from the service in any of the following modes: resignation, YES NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
phased out, in the public or private sector? If YES, give details:
________________________________
________________________________

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: IBANAG TRIBE
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 ADDRESS TEL. NO.

Dr Edward D Garcia, Ph. D. Principal, Aparri School of Arts & Trades 09174044411
ID picture taken within
the last 6 months
Dr Eleazar L Rabaja, Ph. D. Principal, Aparri East National High School 09771261162 3.5 cm. X 4.5 cm
(passport size)
Dean, College of Education, Lyceum of
Dr Eleanor M Malana, Ph. D. 09266927877
Aparri
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines.

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

12464124
COMMUNITY TAX CERTIFICATE NO.

Aparri, Cagayan
ISSUED AT SIGNATURE (Sign inside the box)

01/25/2016 02/28/2016
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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