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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
FIRST NAME
MIDDLE NAME3. NAME EXTENSION (e.g. Jr., Sr.)
4. DATE OF BIRTH (mm/dd/yyyy) 1/11/1989 16. RESIDENTIAL ADDRESS
DACANAY RD., BGY. SAN MANUEL, PUERTO PRINCESA CITY5. PLACE OF BIRTH PUERTO PRINCESA CITY
6. SEX
7. CIVIL STATUS ZIP CODE 530017. TELEPHONE NO. N/A18. PERMANENT ADDRESS
DACANAY RD., BGY. SAN MANUEL, PUERTO PRINCESA CITY8. CITIZENSHIP FILIPINO
9. HEIGHT (m) 1.63 m
10. WEIGHT (kg) 62 kg ZIP CODE 5300
11. BLOOD TYPE A 19. TELEPHONE NO. N/A
GSIS ID NO. N/A 20. E-MAIL ADDRESS (if any) N/A
13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any) 9467006720
14. PHILHEALTH NO. 09-025252128-2 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. 04-2496332-5 23. TIN 272-726-505
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME N/A 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME N/A / /
MIDDLE NAME / /
OCCUPATION / /
EMPLOYER/BUS. NAME / /
BUSINESS ADDRESS / /
TELEPHONE NO. / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME ALLEDA 5/28/1964
FIRST NAME ADORITO / /
MIDDLE NAME UBAY / /
27 MOTHER'S MAIDEN NAME / /
SURNAME PALANCA 9/28/1966
FIRST NAME IMELDA / /
MIDDLE NAME PANIS (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28.LEVEL
From To
ELEMENTARY ELEMENTARY 2001 N/A 10th Honor
SECONDARY PALAWAN NATIONAL HIGH SCHOOL HIGH SCHOOL 2005 GRADUATED 2001 2005 N/A
N/A
COLLEGE
PALAWAN STATE UNIVERSITY 2009 GRADUATED 2005 2009 N/A
GRADUATE STUDIES
2012 PRESENT N/A
(Continue on separate sheet if necessary)
Page 1 of 4
A | L | L | E | D | A | | | | | | | | | | | | | | | | | | | | | |
A | L | L | A | N | | | | | | | | | | | | | | | | | | | | | | | |
P | A | L | A | N | C | A | | | | |
12.
NAME OF SCHOOL (Write in
full)
DEGREE COURSE (Write in full)
YEAR GRADUATED
(if graduated)
HIGHEST GRADE/ LEVEL/
UNITS EARNED (if not graduated)
INCLUSIVE DATES OF ATTENDANCE SCHOLARSHIP/
ACADEMIC HONORS RECEIVED
MAASIN ELEM. SCHOOL, BROOKE'S PT. PAL PUERTO PRINCESA PILOT ELEM. SCHOOL
1995 1997
1997 2001
VOCATIONAL /
TRADE COURSE
BACHELOR OF SCIENCE IN ENVIRONMENTAL
SCIENCE
PALAWAN STATEUNIVERSITYGRADUATE SCHOOL
MASTER STUDIES IN ENVIRONMENTAL
MANAGEMENT
Annulled Others, specify ___________
Single Married
Widowed
Separated
/
√x
Male Fem ale /
IV. CIVIL SERVICE ELIGIBILITY
29.RATING PLACE OF EXAMINATION / CONFERMENT
LICENSE (if applicable)
NUMBER
CAREER SERVICE PROFESSIONAL 81.45% 27-May-12 PALAWAN NATIONAL HIGH SCHOOL (MAIN) 08-160450 03-Jul-13
NOTHING FOLLOWS
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
From To
2/15/2010 PRESENT 8,000.00 CONTRACTUAL NO
5/28/2010 12/31/2010 IEC VOLUNTEER STAFF TUBBATAHA MANAGEMENT OFFICE 4,000.00 CONTRACTUAL NO
/ / / / NOTHING FOLLOWS
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
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/ / / /
/ / / /
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE
DATE OF EXAMINATION / CONFERMENT DATE OF
RELEASE
INCLUSIVE DATES (mm/dd/yyyy) 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)
ADMINISTRATIVE AIDE IV/ DATA ENCODER
PROVINCIAL HEALTH OFFICE - KILUSAN LIGTAS MALARIA OFFICE
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
31.POSITION / NATURE OF WORK
From To
MASTERS STUDIES ORGANIZATION, PSU MANALO 6/1/2012 PRESENT N/A MEMBER
ENVIRONMENTAL SCIENCE STUDENTS ASSOCIATION (ESSA) 6/1/2005 4/2/2009 N/A MEMBER
6/1/2007 4/1/2008 N/A MEMBER
NOTHING FOLLOWS / / / /
/ / / /
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (Start from the most recent training.)
32.
From To
BASIC LIFE SUPPORT 7/13/2010 7/14/2010 16 HOURS
NOTHING FOLLOWS / / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
COMPUTER LITERATE N/A
LAY-OUTING (ADOBE PHOTOSHOP) NOTHING FOLLOWS
COMPUTER TROUBLESHOOTING
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
NAME & ADDRESS OF ORGANIZATION (Write in full)
INCLUSIVE DATES
(mm/dd/yyyy) NUMBER OF HOURS
STUDENTS ACTION FOR VITAL ENVIRONMENT OF MOTHER EARTH MOVEMENT
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)
INCLUSIVE DATES OF ATTENDANCE
(mm/dd/yyyy) NUMBER OF HOURS
CONDUCTED/ SPONSORED BY (Write in full)
PHILIPPINE NATIONAL RED CROSS - PALAWAN CHAPTER
NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in full)
MASTERS STUDIES ORGANIZATION, PSU MANALO
HAS KNOWLEDGE IN MICROSOFT OFFICE (word, excel, power point, publisher)
HAS TRAINING IN LEADERSHIP AND MANAGEMENT
36. Are you related by consanguinity or affinity to any of the following :
a.
b.
37 a. Have you ever been formally charged?
b. Have you ever been guilty of any administrative offense?
38.
39.
40. Have you ever been a candidate in a national or local election (except Barangay election)?
41.
a. Are you a member of any indigenous group?If YES, please specify:
b. Are you differently abled?If YES, please specify: ____________________
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.
MS. ANGELIQUE M. SONGCO Abad Santos St., PPC
LOUIE R. OCAMPO, MD, MPH, DFP PEO Compound, Bancao2x, PPC
MS. MARVI R. TRUDEAU Gabinete Bldg., Bgy. Tiniguiban43.
PHOTO
955955
COMMUNITY TAX CERTIFICATE NO.
Puerto Princesa CityISSUED AT
1/14/2013 3/19/2013ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4
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?
If YES, give details: _____________________________________ _____________________________________ _____________________________________
Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________ _____________________________________ _____________________________________
If YES, give details: ________________________________ ________________________________
If YES, give details: ________________________________ ________________________________
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? If YES, give details:
________________________________ ________________________________
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?
If YES, give details: ________________________________ ________________________________
If YES, give details: ________________________________ ________________________________
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:
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.
SIGNATURE (Sign inside the box)
ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)
Computer generated or xerox copy of picture
is not acceptable
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
YES ∕ NO
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