CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes
with "
1. CS ID No.
" and use separate sheet if necessary.
(to be filled up by CSC)
I. PERSONAL INFORMATION
2. SURNAME
FIRST NAME
C | A| P | I |T | U | L | O |
| |
| | | | | | | | | | | | | | |
T | E | R | E | S | I |T | A |
| |
| | | | | | | | | | | | | | |
I|N |O |N |G |
MIDDLE NAME
| |
| |
| | | | |
CAPAS, TARLAC
Male
6. SEX
7. CIVIL STATUS
| | | 3. NAME EXTENSION (e.g. Jr., Sr.)
16. RESIDENTIAL ADDRESS
12/31/1962
4. DATE OF BIRTH (mm/dd/yyyy)
5. PLACE OF BIRTH
BLK. 7, LOT 18, CRISTO REY, CAPAS, TARLAC
Fem ale
Single
Widowed
Married
Separated
Annulled
___________Others, specify18. PERMANENT ADDRESS
ZIP CODE
2315
09099891526
17. TELEPHONE NO.
8. CITIZENSHIP
FILIPINO
BLK. 7, LOT 18, CRISTO REY, CAPAS, TARLAC
9. HEIGHT (m)
1.64M
10. WEIGHT (kg)
68 Kg
11. BLOOD TYPE
"AB"
19. TELEPHONE NO.
09099891526
12. GSIS ID NO.
006005250037
20. E-MAIL ADDRESS (if any)
[email protected]
21. CELLPHONE NO. (if any)
09099891526
22. AGENCY EMPLOYEE NO.
4341771
23. TIN
208-133-364-000
ZIP CODE
13. PAG-IBIG ID NO.
14. PHILHEALTH NO.
07-000-081-367-0
15. SSS NO.
2315
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME
25. NAME OF CHILD (Write full name and list all)
CAPITULO
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAMEJOBALARMO
JAN JOSEF I. CAPITULO
01/21/1995
MIDDLE NA
CUIZON
JAMELLA I. CAPITULO
10 /08 / 1997
OCCUPATION
OFW
JARED KYLE I. CAPITULO
11/16/1999
EMPLOYER/BUS. NAME
SAUDI ELECTRIC COMPANY
JENIERO I. CAPITULO
BUSINESS ADDRESS
KSA
09 / 27 / 2006
/
(Continue on separate sheet if necessary)
INONG
FIRST NAME
GONZALO
MIDDLE NAME
PANTALEON
TELEPHONE NO.
26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME
SURNAME
SORIANO
FIRST NAME
PILAR
MIDDLE NAME
AQUINO
(Continue on separate sheet if necessary)
YEAR
GRADUATED
III. EDUCATIONAL BACKGROUND
28.
NAME OF SCHOOL
LEVEL
(Write in
DEGREE COURSE
(Write in full)
full)
(if
graduated)
INCLUSIVE DATES OF
ATTENDANCE
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
From
To
ELEMENTARY
CAPAS WEST CENTRAL
ELEMENTARY
1979
GRADUATE
1969
1975
SECONDARY
VOCATIONAL /
DOMINICAN SCHOOL
HIGH SCHOOL
1979
GRADUATE
1975
1979
UNIVERSITY OF BAGUIO
BSEED
1983
GRADUATE
1979
1983
PAMPANGA AGRICULTURAL COLLEGE
Master in Professional
1999
Studies
GRADUATE
1997
1999
PAMPANGA AGRICULTURAL COLLEGE
Doctor of Education
Academic
Requirements
2008
2011
COLLEGE
TRADE
COURSE
GRADUATE STUDIES
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
(Continue on separate sheet if necessary)
Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER
SPECIAL LAWS/ CES/ CSEE
LET
RATING
75.40%
DATE OF
EXAMINATION /
CONFERMENT
08/01/1997
LICENSE (if applicable)
PLACE OF EXAMINATION / CONFERMENT
TARLAC CITY
NUMBER
0324008
DATE OF
RELEASE
03-02-98
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
INCLUSIVE DATES
(mm/dd/yyyy)
30.
From
POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
To
(Write in full)
GOV'T
SERVICE
MONTHLY
SALARY
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
(Yes /
No)
(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
HOURS
(mm/dd/yyyy)
(Write in full)
From
POSITION / NATURE OF WORK
To
(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
in full)
From
ORIENTATION / BRIEFING on the NATIONWIDE
OUT OF BATCH 7
ROLL
NUMBER OF
HOURS
(mm/dd/yyyy)
CONDUCTED/ SPONSORED BY
(Write in full)
To
08 / 24 /11
08 / 25 /11
16
DEPED/ICTU TECHNICAL SERVICES
NATIONAL SEMINAR on CONSTRUCTION & INTERPRETATION
12 / 28 /09
12 /30 /09
24
DEPED
SOUTHEAST ASIA MINISTRY of EDUCATION ORGANIZATION
TEACHERS' CAMP
10 / 06 /04
10 / 09 /04
32
SEAMEO-QEE
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
33.
SPECIAL SKILLS / HOBBIES:
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
34.
(Write in full)
35.
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
TYPING
COMPUTER LITERATE
(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
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
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?
YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
b. Within the fourth degree (for Local Government Employees):
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
b. Have you ever been guilty of any administrative offense?
NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
YES
NO
If YES, give details:
________________________________
________________________________
regulation by any court or tribunal?
39. Have you ever been separated from the service in any of the following modes: resignation,
YES
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
phased out, in the public or private sector?
NO
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?
b.
Are you differently abled?
c.
Are you a solo parent?
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME
ADDRESS
TEL. NO.
MR. VICTOR O. SANTOS JR
O'DONNELL, CAPAS, TARLAC
9195699221
MR. ARTHUR GUERRERO
O'DONNELL, CAPAS, TARLAC
9219639919
KGD. MERLY T. VILLANUEVA
O'DONNELL, CAPAS, TARLAC
9213653708
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.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
05167471
COMMUNITY TAX CERTIFICATE NO.
CAPAS, TARLAC
ISSUED AT
01/12/2012
ISSUED ON (mm/dd/yyyy)
SIGNATURE (Sign inside the box)
09/12/2012
DATE ACCOMPLISHED
RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4
