Vous êtes sur la page 1sur 16

CS FORM 212 (Revised 2005)

2. SURNAME S A L A S
FIRST NAME J O C E L Y N
MIDDLE NAME T A M O N D O N G
4.
5. PLACE OF BIRTH
6. SEX

R Male Female
R Male Female R
CIVIL STATUS
Single Widowed R
R Male Female
R Male Female
R Married Separated
Married
R Male Female
17. TELEPHONE NO.
Annulled ______
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.
24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all)
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.

26.


27. MOTHER'S MAIDEN NAME


DATE OF BIRTH (mm/dd/yyyy)
16. RESIDENTIAL ADDRESS
O'DONNELL, CAPAS TARLAC
Male Female
PERSONAL DATA SHEET
Print legibly. Mark appropriate boxes with " P " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)
I. PERSONAL INFORMATION
3. NAME EXTENSION (e.g. Jr., Sr.)
PANDO, CONCEPCION, TARLAC FILIPINO
1.35 M
50 KLS. ZIP CODE 2316
7.
Single Widowed ZIP CODE 2315
Separated
Annulled Others, Specify _____
18. PERMANENT ADDRESS
21. CELLPHONE NO. (if any) 09214676967
19 - 000322801 - 4 22. AGENCY EMPLOYEE NO. 4329976
"O" 19. TELEPHONE NO. N/A
63050702245 20. E-MAIL ADDRESS (if any)
N/A
23. TIN 173 - 641 - 742
II. FAMILY BACKGROUND
N/A DATE OF BIRTH (mm/dd/yyyy)
MIDDLE NAME ESPINOSA
(Continue on separate sheet if necessary)
FATHER'S SURNAME SALAS
ELEMENTARY CORAL CAMBING ELEM. SCHOOL 1975 1969 1975
FIRST NAME CLARITA
MIDDLE NAME TAAL (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28.
LEVEL
NAME OF SCHOOL
(Write in full)
DEGREE COURSE
(Write in full)
YEAR
GRADUATED
(if graduated)
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
INCLUSIVE DATES OF
ATTENDANCE
GRADUATE STUDIES
HARVADIAN COLLEGES
MASTER OF ARTS
IN EDUCATION
36 UNITS 1999 2003
1987 1989
COLLEGE TARLAC COLLEGE OF
TECHNOLOGY
B.S. IN HOME
TECHNOLOGGY
1983 1979
(Continue on separate sheet if necessary)
1983
VOCATIONAL /
TRADE COURSE
TARLAC COLLEGE OF
TECHNOLOGY
B.E.Ed.
SECONDARY TARLAC HIGH SCHOOL 1979 1975 1979
1989
To
SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
From
SURNAME TAMONDONG
FIRST NAME PACIFICO













O'DONNELL, CAPAS TARLAC
PERSONAL DATA SHEET
(to be filled up by CSC)
I. PERSONAL INFORMATION
3. NAME EXTENSION (e.g. Jr., Sr.)
PANDO, CONCEPCION, TARLAC
2316
2315
09214676967
4329976
N/A
173 - 641 - 742
II. FAMILY BACKGROUND
DATE OF BIRTH (mm/dd/yyyy)
(Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
(Continue on separate sheet if necessary)
SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
Page 1 of 4
29.
NUMBER
79.36% 068634
30.




















PBET DEC. 10, 1989 TARLAC, TARLAC
IV. CIVIL SERVICE ELIGIBILITY
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER
SPECIAL LAWS/ CES/ CSEE
RATING
DATE OF
EXAMINATION /
CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
LICENSE (if applicable)
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
INCLUSIVE DATES
(mm/dd/yyyy)
POSITION TITLE
(Write in full)
DEPARTMENT / AGENCY / OFFICE /
COMPANY
(Write in full)
MONTHLY
SALARY
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
STATUS OF
APPOINTMENT
From To
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
DATE OF
RELEASE
JUNE 4,
1990
IV. CIVIL SERVICE ELIGIBILITY
LICENSE (if applicable)
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
GOV'T
SERVICE
(Yes / No)
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4





/ / / /














33. SPECIAL SKILLS / HOBBIES: 34. 35.
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)
NUMBER OF
HOURS
POSITION / NATURE OF WORK
From To
To
DIVISION EPP SEMINAR WORKSHOP ON EPP 08 03 11 08 05 11
(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)
NUMBER OF
HOURS
CONDUCTED/ SPONSORED BY
(Write in full)
From
COOKING, CROCHETING
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
(Write in full)
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
POSITION / NATURE OF WORK
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (Start from the most recent training.)
CONDUCTED/ SPONSORED BY
(Write in full)
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
36.
a.
b.
37
38.
39.
40.
41.
a.
b.
c.
42.
NAME ADDRESS
O'DONNELL CAPAS, TARLAC
PANDO, CONCEPCION, TARLAC
CONCEPCION, TARLAC
05172501
COMMUNITY TAX CERTIFICATE NO.
CAPAS, TARLAC
ISSUED AT
01 - 13 - 2012
ISSUED ON (mm/dd/yyyy)
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?
YES R NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
Within the fourth degree (for Local Government Employees): appointing
authority or recommending authority where you will be appointed?
YES R NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
a. Have you ever been formally charged?
YES R NO
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense?
YES R NO
If YES, give details:
________________________________
________________________________
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court
or tribunal?
YES R NO
If YES, give details:
________________________________
________________________________
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?
YES R NO
If YES, give details:
________________________________
________________________________
Have you ever been a candidate in a national or local election (except Barangay election)?
YES R NO
If YES, give details:
________________________________
________________________________
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?
YES R NO
If YES, please specify: ____________________
Are you differently abled?
YES R NO
If YES, please specify: ____________________
ALLADIN M. QUIAMBAO
Are you a solo parent?
YES R NO
If YES, please specify: ____________________
REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
TEL. NO.
VICTOR O. SANTOS JR.
HERMIE E. NOBLES
DATE ACCOMPLISHED
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.
SIGNATURE (Sign inside the box)
CS FORM 212 (Revised 2005), Page 4 of 4
PHOTO
RIGHT THUMBMARK
YES R NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
YES R NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
YES R NO
If YES, give details:
________________________________
________________________________
YES R NO
If YES, give details:
________________________________
________________________________
YES R NO
If YES, give details:
________________________________
________________________________
YES R NO
If YES, give details:
________________________________
________________________________
YES R NO
If YES, give details:
________________________________
________________________________
YES R NO
If YES, please specify: ____________________
YES R NO
If YES, please specify: ____________________
YES R NO
If YES, please specify: ____________________
REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)



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




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

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