CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15143489

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 SEGUNDO
FIRST NAME MICHAEL
MIDDLE NAME MANIPON 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS 189 Paturo St. Warey, MALASIQUI, PANGASINAN

4. DATE OF BIRTH (mm/dd/yyyy) 11 / 15 / 1991
5. PLACE OF BIRTH Malasiqui, Pangasinan
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 2421
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS 189 Paturo St. Warey, MALASIQUI, PANGASINAN

8. CITIZENDSHIP filipino
9. HEIGHT (m)

10. WEIGHT (kg) 164 ZIP CODE 2421

11. BLOOD TYPE O+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) msegundo47@gmail.com

13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any) 09126087708
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 02-3653460-9 23. TIN

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Segundo

FIRST NAME Marcelo

MIDDLE NAME Deldio

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Manipon

FIRST NAME Angela

MIDDLE NAME Espinoza

III. EDUCATIONAL BACKGROUND

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

J.C. Macaranas Elementary

ELEMENTARY 2005
School

SECONDARY Malasiqui Catholic School 2009

VOCATIONAL/ TRADE
COURSE

Pangasinan State University Bachelor of Arts in

COLLEGE 2013
Bayambang Campus English

Bachelor of
GRADUATE STUDIES Perpetual Help College 2013 18
Secondary Education

IV. CIVIL SERVICE ELIGIBILITY

SEGUNDO, MICHAEL MANIPON - T15143489 CS FORM 212 (Revised 2005), Page 1 of 3

29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE
LET (LICENSURE EXAMINATION FOR
75.00 03 / 29 / 2015 Manila 1363690 06/09/2015
TEACHER)

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

11/17/2014 03/31/2016 Subject Teacher St. John Institute 5,500 0-0 No

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

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

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

32. INCLUSIVE DATES OF
ATTENDANCE
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
(Write in full) HOURS (Write in full)
From To

basic computer application Microsoft Word, Excel & Powerpoint 12 / 09 / 2015 12 / 19 / 2015

Ebeis bosy roll out and training workshop for private school 09 / 24 / 2015

Division Training Workshop on Campus Journalism 09 / 09 / 2015 09 / 11 / 2015

Division Refresher course for officiating officials 08 / 21 / 2015 08 / 23 / 2015

Heritage and Tourism as part of the Pangasinan Tourism Month 09 / 30 / 2014

2014 Pangasinan II Division Sports meet in Taekwondo 09 / 22 / 2014 09 / 24 / 2014

Division Training Workshop on Campus Journalism for School Paper

09 / 02 / 2014 09 / 04 / 2014
Advisers and Critics

Simultaneous Division- Workshop for Untrained and Newly Hired Teachers

06 / 23 / 2014 06 / 25 / 2014
of K to 12 Basic Education Program

Region 1 Gastpe Guideline orientation & Fafe online Encoding System

05 / 22 / 2014
Training

VIII. OTHER INFORMATION

33. 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION: 35. MEMBERSHIP IN ASSOCIATION / ORGANIZATION
SPECIAL SKILLS / HOBBIES:
(Write in full) (Write in full)

Editing Pictures

making Slideshows

computer literate

SEGUNDO, MICHAEL MANIPON - T15143489 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): 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 If YES, give details:
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:_______________________
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.

Julio Centeno Warey Malasiqui Pangasinan 09179030363

Pablo S. Manipon Jr. Barangay Paltok Quezon City 09096635305

Luriza P. Cariaga Bayambang, Pangasinan 09308420173

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

00264578

COMMUNITY TAX CERTIFICATE NO.

Malasiqui, Pangasinan

ISSUED AT SIGNATURE (Sign inside the box)

2017-01-06 01 / 06 / 2017

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

SEGUNDO, MICHAEL MANIPON - T15143489 CS FORM 212 (Revised 2005), Page 3 of 3