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
ABRINA
2. SURNAME
FIRST NAME
KENAN
MIDDLE NAME
LAVEGA
3. NAME EXTENSION (e.g. Jr., Sr.)
5. PLACE OF BIRTH
16. RESIDENTIAL ADDRESS
8/27/1994
4. DATE OF BIRTH (mm/dd/yyyy)
BAGONG BAYAN, EL NIDO, PALAWAN
Male
6. SEX
7. CIVIL STATUS
BAGONG BAYAN, EL NIDO, PALAWAN
Female
Single
Widowed
Married
Separated
Annulled
Others, specify ___________ 18. PERMANENT ADDRESS
8. CITIZENSHIP
Filipino
9. HEIGHT (m)
5'7"
ZIP CODE
5313
NONE
17. TELEPHONE NO.
BAGONG BAYAN, EL NIDO, PALAWAN
10. WEIGHT (kg)
54 kg
11. BLOOD TYPE
19. TELEPHONE NO.
NONE
12. GSIS ID NO.
N/A
20. E-MAIL ADDRESS (if any)
[email protected]
13. PAG-IBIG ID NO.
N/A
21. CELLPHONE NO. (if any)
09460444000
14. PHILHEALTH NO.
09-025439846-1
22. AGENCY EMPLOYEE NO.
N/A
15. SSS NO.
04-27228368
23. TIN
322-266-286
ZIP CODE
5313
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME
25. NAME OF CHILD (Write full name and list all)
N/A
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME
N/A
MIDDLE NAME
N/A
OCCUPATION
N/A
EMPLOYER/BUS. NAME
N/A
BUSINESS ADDRESS
N/A
TELEPHONE NO.
N/A
ABRINA
FIRST NAME
FLORESTO
MIDDLE NAME
SALDIVAR
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME
SURNAME
LAVEGA
FIRST NAME
PUJRISIMA
MIDDLE NAME
LAGRADA
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28.
YEAR
GRADUATED
NAME OF SCHOOL
LEVEL
(Write in
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
DEGREE COURSE
(Write in full)
full)
(if graduated)
INCLUSIVE DATES OF
ATTENDANCE
From
To
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
ELEMENTARY
BAGONG BAYAN, ELEM. SCHOOL
GRADUATE
2005
GRADUATE
6/1999
03/2005
WITH HONORS
SECONDARY
VOCATIONAL /
BAGONG BAYAN, NAT'L HIGH SCHOOL
GRADUATE
2010
GRADUATE
6/2005
4/2010
WITH HONORS
FULLBRIGHT COLLEGE, PUERTO
PRINCESA CITY
BS. CRIM
2014
GRADUATE
6/2010
4/2014
NONE
N/A
N/A
COLLEGE
COURSE
TRADE
GRADUATE STUDIES
N/A
(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
LICENSURE EXAM. FOR TEACHERS
RATING
75.00%
LICENSE (if applicable)
DATE OF
EXAMINATION /
CONFERMENT
8/26/2001
PLACE OF EXAMINATION / CONFERMENT
PALAWAN NATIONAL SCHOOL
NUMBER
733908
DATE OF
RELEASE
11/15/2001
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
INCLUSIVE DATES
(mm/dd/yyyy)
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)
7/3/2000
12/4/2005
TEACHER I
BAGONG BAYAN NHS
3,000.00
10-1
(Locally
paid)
YES
12/5/2005
to present
TEACHER I
BAGONG BAYAN NHS
19,12200
11-3
REG.PER
YES
/
(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
31. NAME & ADDRESS OF ORGANIZATION
INCLUSIVE DATES
(Write in full)
NUMBER OF
HOURS
(mm/dd/yyyy)
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)
(mm/dd/yyyy)
From
NUMBER OF
HOURS
CONDUCTED/ SPONSORED BY
(Write in full)
To
MASS TRAINING OF YEAR II TEACHERS ON THE 2010 SEC
5/10/2011
5/13/2011
36
DEPED
DIVISION EDUC.DEV'T PLAN 2011-2016 CONSULTATIVE
CONFERENCE
12/20/2010
12/21/2010
24
DEPED
2010 DIVISION SEMINAR WORKSHOP ON GENDER AND
DEVELOPMENT
12/21/2010
DEPED
DIVISION EDUCATION DEV'T PLAN WORKSHOP
10/21/2010
10/22/2010
24
DEPED
MASS TRAINING OF YEAR I TEACHERS ON THE 2010 SEC
6/7/2010
6/11/2010
40
DEPED
CLUSTER ORIENTATION WORKSHOP ON THE 2009 NATIONAL
10/5/2009
TEXTBOOK DELIVERY AND SUPPLY/PROPERTY MGT PROG.
REORIENTATION ON SCHOOL MGT FOR SECONDARY
SCHOOL HEADS
8/6/2009
8
8/7/2009
16
NAPSSHI
DIVISION ROLL-OUT OF SBM,SIP,SGC,NCBTS,TSNA AND IPPD
5/19/2009
ADVOCACY
5/23/2009
36
DEPED
FIRST REGIONAL PUBLIC SECONDARY SCHOOL HEAD
FORUM
2/27/2008
2/29/2008
24
NAPSSHI
10/24/2007
7/23/2007
7/25/2007
24
DEPED
ADMINISTRATIVE CASES AND ON THE POLL DUTIES OF
TEACHERS.
3/7/2007
3/8/2007
16
DEPED
BASIC EDUCARION REFORM AGENDA FOR SEC. TEACHERS
11/16/2007
DEPED
3/1/2007
DEPED
10/25/2010
2007 NATIONAL TEXTBOOK DELIVERY PROGRAM CLUSTER
ORIENTATION WORKSHOP
DIVISION ON ORIENTATION ON ADOPT A SCHOOL PROGRAM
FOR PSDS,COORDINATING PRIN.MASP COOR,AND
SEC,SCHOOL
SCHOOL
SEEMINAR ONPRIN./
REVISED
RULESHEAD
OF PROCEDURE FOR
THE DIVISION ECHO TRAINING ON SCHOOL MAPPING
EXERCISE AND ORIENTATION OF THE GIS BASED SCHOOL
PROFILING SYSTEM.
CONFERENCE WORKSHOP PHILIPPINE EFA PLAN 2015 AND
OTHER STATISTICAL IMPROVEMENT ACTIVITIES.
DEPED
(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)
(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):
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?
YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
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
regulation by any court or tribunal?
39.
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?
40.
Have you ever been a candidate in a national or local election (except Barangay election)?
YES
NO
If YES, give details:
________________________________
________________________________
YES
NO
If YES, give details:
________________________________
________________________________
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.
ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)
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.
Computer generated
or xerox copy of picture
is not acceptable
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign inside the box)
ISSUED ON (mm/dd/yyyy)
DATE ACCOMPLISHED
RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4
