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

UTRERA TERESITA AGBISIT 05/15/1954

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

MAGSINGAL, ILOCOS 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 5'2 59 KGS. O 854BF-TALI-01-7 0022224711 05-0000257620 N/A UTRERA DANILO CERIA OVERSEAS CONTRACT WORKER N/A BARCELONA, SPAIN 34602685308
(Continue on separate sheet if necessary)

2730 N/A tiring011554@yahoo.com 0917-4999823 021033-0089775 115-639-730

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)

MARY CLAIRE A. UTRERA DANTE A. UTRERA

03/09/1986 05/12/1988
/ / / / / / / / / / / / / / / / / / / / / /

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

AGBISIT LEONIDES (DECEASED) OLIVAS URUBIO HILARIA PASCUA

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

MAGSINGAL SOUTH CENTRAL SCHOOL THE MAGSINGAL INSTITUTE N/A NORTH LUZON TEACHER COLLEGE LAOAG CITY

ELEMENTARY HIGH SCHOOL N/A

BS ELEMENTARY EDUCATION

1966 1972 N/A 1976

GRADUATED GRADUATED N/A GRADUATED

1960 1966 N/A 1972

1966 1972 N/A 1976

NONE 1ST HONORABLE MENTION N/A NONE

SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

GRADUATE STUDIES

UNIVERSITY OF NORTHERN PHILS VIGAN MASTER OF ARTS IN EDUCATION CITY, ILOCOS SUR

N/A

24 UNITS

1978

1981

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

PROFESSIONAL BOARD EXAM FOR TEACHERS

72.14%

05/25/1980

SAN FERNANDO, LA UNION

0405521

07/27/98

(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)

12/13/2011 12/13/2009 06/30/2007 06/30/2005 01/12/2004 07/12/2002 01/01/2000 11/12/1999 01/11/1997 10/03/1996 01/01/1996 01/01/1995 01/01/1994 01/12/1993 01/01/1992 07/01/1989 03/01/1987 01/01/1985 01/06/1981 09/12/1976

TO DATE 01/12/2010 01/12/2008 01/02/2006 06/30/2004 01/12/2003 06/30/2001 12/13/1999 11/01/1998 01/01/1997 12/03/1996 12/13/1995 12/31/1994 12/31/1993 01/11/1993 12/03/1991 06/30/1989 02/28/1987 12/31/1984 09/09/1981

TEACHER III TEACHER III TEACHER III TEACHER III TEACHER III TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER II TEACHER 1 TEACHER 1

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 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 DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION
(Continue on separate sheet if necessary)

21,867.00 20,700.00 18,753.00 11,621.00 11,334.00 11,068.00 10,541.00 9,583.00 7,349.00 7,813.00 6,243.00 5,009.00 4,009.00 3,309.00 3,196.00 3,102.00 1,764.00 1,604.00 870.001,096.00 367.00666.00

13-3 13-3 13-3 12-3 12-3 11-3 11-3 11-2 11-2 11-2 11-2 11-2 11-2 11-2 11-2 11-2 11-2 11-2 10-1 10-1

PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PROVISIONAL SUBTITUTE

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES

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 1 DISTRICT TRAINING FOR ELEMENTARY TEACHERS IN ENGLISH LANGUAGE & READING ENHANCEMENT PROG TEACHING STRATEGIES & TEST CONSTRUCTION SEMINAR WORKSHOP ONE DAY CONGRESS FOR DEPED PERSONNEL IN THE DIVISION OF ILOCOS SUR RUBRICS & PORTFOLIO ASESSMENT OF AUTHENTIC LEARNING SEMINAR WORKSHOP DISTRICT ECHO SEMINAR ON THE CONTENT OF ELEMENTARY MATHEMATICS VI SEMINAR WORKSHOP IN READING & THE REVISION OF THE FILIPINO ALPHABET
DIV TRAINING OF PUBLIC ELEM & SEC SCHOOL TEACHERS ON THE IMPLEMENTATION OF 2002 BASIC EDUC CURRICULUM REF

05/18/2012 08/20/2010 04/19/2006 06/23/2006 06/14/2004 09/05/2003 07/06/2002 05/06/2002 08/28/2000 04/15/1996 09/10/1994 10/10/1992 10/16/1992 08/20/1982 08/13/1980

05/22/2013 08/21/2010 / / / / / / / /

40HRS 8HRS 8HRS 8HRS 8HRS 8HRS 16HRS 40HRS 40HRS 60HRS 24HRS 16HRS 8HRS 24HRS 24HRS

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

07/07/2002 05/10/2002 09/14/2000 04/21/1996 09/11/1994 10/02/1992 10/17/1992 08/22/1982 08/15/1980

CLUSTER SCHOOL BASED IN SERVICE TRAINING FOR SCIENCE &MATH TEACHERS PAGSASALING WIKA AT PAGGAMIT NG FILIPINO SA LAHAT NG KOMUNIKASYON TRAINING PROGRAM FOR SCIENCE & MATH EDUCATION MANPOWER DEVELOPMENT PROJECT DISTRICT SEMINAR WORKSHOP FOR GRADES 3-6 MUSIC TEACHERS ON MUSIC READING & SCHOOL BAND MNG'T BASIC TRAINING COURSE FOR REFRESHER SEMINAR FOR KAWAN LEADERS SPECIALIZATION COURSE (STAR LEVEL) BASIC LEADERSHIP COURSE (GIRL SCOUT)

(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 & DANCING

N/A

MAGSINGAL DISTRICT TEACHER ASSOCIATION ILOCOS SUR TEACHER ASSOCIATION PPSTA

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

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. ROSE VITCHIE R. CALPITO MRS. IMELDA P. ARRELLANO
43.

SAN CLEMENTE, MAGSINGAL I.SUR PANAY, MAGSINGAL I.SUR PANAY, 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. 23135164
COMMUNITY TAX CERTIFICATE NO.

Computer generated or xerox copy of picture is not acceptable

PHOTO

MAGSINGAL ILOCOS 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