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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)

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


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

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /


CS FORM 212 (Revised 2005), 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 / / / /

/ / / /


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 / / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /


VIII. OTHER INFORMATION

33. SPECIAL SKILLS / HOBBIES: 34. 35.

COMPUTER LITERATE N/A

LAY-OUTING (ADOBE PHOTOSHOP) NOTHING FOLLOWS

COMPUTER TROUBLESHOOTING



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


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: ________________________________ ________________________________


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?



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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