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

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| S |H | A | N | E | 09/29/1983

A | B | I | N |G | O |N | A |

3. NAME |EXTENSION| (e.g. Jr., Sr.) | | | |

| N/A |

16. RESIDENTIAL ADDRESS

QUEZON CITY
Male Single Married Annulled Female Widowed Separated
17. TELEPHONE NO. ZIP CODE

120 Laurel Street., Freedom Park 6, Batasan Hills,Quezon City

1126 N/A

Others, specify ___________ 18. PERMANENT ADDRESS

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 1.53 m 50 kg "O" 956-1152035-01-0 007062782803 03-000204305-6 N/A N/A

19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN ZIP CODE

120 Laurel Street., Freedom Park 6, Batasan Hills,Quezon City

1126 N/A rade_shine@yahoo.com 09156257758 CE-211-845 900-875-917

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. (Continue on separate sheet if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

N/A

/ / / / / / / / / / /

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

FLORES MANUEL ELITEO

ABINGONA VIRGINIA SALAZAR

(Continue on separate sheet if necessary)

/ /

III. EDUCATIONAL BACKGROUND

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

(if graduated)

ELEMENTARY SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

QUIRINO ELEMENTARY SCHOOL ROOSEVELT COLLEGE-QUIRINO N/A POLYTECHNIC UNIVERSITY OF THE PHILIPPINES-STA. MESA

PRIMARY SECONDARY

1996 2000

GRADUATED GRADUATED

1990 1996

1996 2000

N/A N/A

BACHELOR IN BANKING AND FINANCE

2004

GRADUATED

2000

2004

SCHOLARSHIP & YOUTH DEV'T. PROGRAM (SYDP)

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

CS-SUBPROFESSIONAL

83.38% OCT 18, 2002

CSC-NCR (CAT)

209081WE

OCT 18, 2002

(Continue on separate sheet if necessary)

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

06/01/2011 06/24/2010 07/01/2009 07/01/2008 07/01/2007 08/01/2005 09/21/2004 / / / / / / / / / / / / / / / / / / / / / / / / / /

present 05/31/2011 06/23/2010 06/30/2009 06/30/2008 06/30/2007 07/31/2005 / / / / / / / / / / / / / / / / / / / / / / / / / /

ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III CLERK I

AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER

9,628 8,854 8,080 7,307 6,643 6,039 6,039

SG-3 SG-3 SG-3 SG-3 SG-3 SG-3 SG-3

CASUAL CASUAL CASUAL CASUAL CASUAL CASUAL CASUAL

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

/ / / / /

/ / / / /

/ / / / /

/ / / / /

(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)

VALUES ORIENTATION WORKSHOP CIVILIAN PERSONNEL BASIC COURSE CLASS 21-2011 SEMINAR ON PUBLIC SERVICE ETHICS AND ACCOUNTABILITY (PSEA) SERVICE ETIQUETTE AND PROTOCOL SEMINAR CLASS 02-2008 CIVILIAN PERSONNEL BASIC ORIENTATION SEMINAR CLASS 11-2004

09/21/2011 06/01/2011 10/14/2010 07/30/2008 10/04/2004 / / / / / / / / / / / / / / / / / / / /

09/23/2011 07/01/2011 10/15/2010 08/01/2008 10/15/2004 / / / / / / / / / / / / / / / / / / / /

N/A 184 16 N/A 40

ANTI-RED TAPE COMMITTEE, AFP MEDICAL CENTER

OFFICE OF THE ADJUTANT GENERAL, GENERAL HEADQUARTERS, AFP

CIVIL SERVICE COMMISSION-NCR

OFFICE OF THE ASSISTANT CHIEF OF STAFF FOR OPERATIONS, AFP MEDICAL CENTER OFFICE OF THE ASSISTANT CHIEF OF STAFF FOR PERSONNEL, AFP MEDICAL CENTER

(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)

SINGING & DANCING

1. LETTER OF COMMENDATION FROM BGEN ARIEL A ZERRUDO AFP DTD 01 JANUARY 2010 2. LETTER OF COMMENDATION FROM COL TYRONE O NONATO MAC (GSC) DTD 29 NOV 2009 3. LETTER OF COMMENDATION FROM BGEN ARIEL A ZERRUDO AFP DTD 30 JANUARY 2009
4. CERTIFICATE OF RECOGNITION FROM DRA CHERILYN R LUZANO MD, CEA PRESIDENT DTD 29 AUG 2008

AFPMC CIVILIAN EMPLOYEES ASSOCIATION

5.LETTER OF COMMENDATION FROM BGEN EFREN O VERAN AFP DTD 25 JUN 2007
(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
OFFICE OF THE DEPUTY COMMNADER FOR ADMIN, AFP MEDICAL CENTER

TEL. NO.

COLONEL GUEVARRA, ROSARIO D VILLANUEVA, MIRIAM M MS MERLIE B MOGA

43.

9211764 9250369 9318163

SAN MATEO, RIZAL CIVIL SVC COMMISSION HEAD OFFICE

ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size)

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. 06482316
COMMUNITY TAX CERTIFICATE NO.

Computer generated or xerox copy of picture is not acceptable

PHOTO

Quezon City
ISSUED AT SIGNATURE (Sign inside the box)

02/10/2012
ISSUED ON (mm/dd/yyyy)

03/19/2012
DATE ACCOMPLISHED RIGHT THUMBMARK

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