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 NAME

TABULOC EVELYN ASUNCION 01/08/1982

Male Single Married Annulled Fem ale Widowed Separated Others, specify ___________
17. TELEPHONE NO. 18. PERMANENT ADDRESS ZIP CODE 16. RESIDENTIAL ADDRESS 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

MARATUDO, MAGSINGAL I. SUR

MARATUDO, MAGSINGAL ILOCOS SUR 2730 N/A MARATUDO, MAGSINGAL ILOCOS SUR
ZIP CODE 19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11. BLOOD TYPE 12. GSIS ID NO. 13. PAG-IBIG ID NO. 14. PHILHEALTH NO. 15. SSS NO.

FILIPINO 5'0 55 KGS. O LP-82010800265 N/A 05-000066845-9 N/A TABULOC FRANCIS TADENA DRIVING N/A N/A N/A
(Continue on separate sheet if necessary)

2730 N/A N/A 0905-6456007 938-171-277

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

BEA FRANCINE KATE A. TABULOC ZEA ROXETTE A. TABULOC ZYRONE A. TABULOC

01/22/2007 01/31/2008 10/26/2010

/ / / / / / / / / / / / / / / / / / / /

26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME

ASUNCION MODESTO USANO UNCIANO VALENTINA UCLOSIN

YEAR GRADUATED (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

(if graduated)

ELEMENTARY

MAAS-ASIN ELEMENTARY SCHOOL BACSIL NATIONAL HIGH SCHOOL N/A UNIVERSITY OF NORTHERN PHILS VIGAN CITY, ILOCOS SUR

N/A N/A N/A

BS ELEMENTARY EDUCATION

1994 1998 N/A 2002

GRADUATED GRADUATED N/A GRADUATED

1988 1994 N/A 1998

1994 1998 N/A 2002

N/A N/A N/A N/A

SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

GRADUATE STUDIES

N/A

N/A

N/A

N/A

N/A

N/A

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 RATING DATE OF EXAMINATION / CONFERMENT LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE

LICENSURE EXAMINATION FOR TEACHERS

75.00%

08/25/2002

BAGUIO CITY

0789372

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES (mm/dd/yyyy) From To 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)

06/01/2012 06/01/2011 06/24/2010 07/01/2009 07/01/2008 06/08/2008 07/01/2007 06/28/2005 10/12/2004

TO DATE TO DATE TO DATE 06/23/2010 06/30/2009 06/30/2008 06/27/2008 06/30/2007 12/21/2004

TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I

DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION

18,922.00 17,318.00 15,900.00 14,483.00 12,328.00 11,207.00 10,933.00 9,939.00 9,939.00 11-2 11-2 10-2 10-2 10-1 10-1 10-1

PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT SUBSTITUTE

YES YES YES YES YES YES YES YES 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 (Write in full) INCLUSIVE DATES (mm/dd/yyyy) From To NUMBER OF HOURS POSITION / NATURE OF WORK

N/A / / / /

N/A / / / / / / / /

N/A / / / /

N/A

N/A

(Continue on separate sheet if necessary)

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

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

K TO 12 FOR GRADE II DISTRICT TRAINING FOR ELEMENTARY TEACHERS IN ENGLISH LANGUAGE & READING ENHANCEMENT PROG DepED UNIFIED TEACHERS TRAINING IN ENGLISH, MATH & SCIENCE BEGINNING TEACHERS CORE VALUES FORMATION WORKSHOP ON UPGRADING THE ELEM TEACHERS PEDAGOGICAL CONTENT KNOWLEDE STRATEGIES BASIC TRAINING COURSE FOR TROOP LEADER OUTDOOR LEADERSHIP COURSE AGE LEVEL COURSE BASIC LEADERSHIP COURSE TEST STRATEGIES & TEST CONSTRUCTION

05/18/2012 08/20/2010 05/21/2007 04/26/2007 10/23/2006 10/29/2005 9/2-4/2005 08/26/2005 07/29/2005 04/19/2005

05/22/2013 08/21/2010 05/25/2007 04/28/2007 10/28/2006 10/31/2005 9/10-11/2005 08/28/2005 07/31/2005 04/19/2005

40HRS 16HRS 40HRS 24HRS 48HRS 24HRS 32HRS 24HRS 24HRS 8HRS

NARVACAN NAT'L HIGH SCHOOL DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

COOKING & SINGING

N/A

MAGDISTA GIRL SCOUTS OF THE PHILIPPINES BOY SCOUTS OF THE PHILIPPINES

(Continue on separate sheet if necessary) CS FORM 212 (Revised 2005), Page 3 of 4

36. a.

Are you related by consanguinity or affinity to any of the following : 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? Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?
YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________

b.

YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________

YES NO

37

a. Have you ever been formally charged?

b. Have you ever been guilty of any administrative offense?

If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO

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?

If YES, give details: ________________________________ ________________________________

YES NO

40.

Have you ever been a candidate in a national or local election (except Barangay election)?

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: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent? YES NO If YES, please specify: ____________________ YES NO If YES, please specify: ____________________ YES NO If YES, please specify: ____________________

a. b. c.

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)

MR. GEOFFREY T. UNIDA MRS. IMELDA P. ARELLANO MR. RODOLFO AGNO

43.

SAN CLEMENTE, MAGSINGAL I.SUR PANAY, MAGSINGAL I.SUR MARATUDO, MAGSINGAL I.SUR

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. 23135160
COMMUNITY TAX CERTIFICATE NO.

Computer generated or xerox copy of picture is not acceptable

PHOTO

MAGSINGAL, I. SUR
ISSUED AT SIGNATURE (Sign inside the box)

01/14/2014
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4