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 T| I | T | O | | | | | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME M | A| R | Y | | G | R | A | C | E | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME M | A | G | L | A| N | G | I | T | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 11 /29 /1978 16. RESIDENTIAL ADDRESS

1175 PEPING GAMO STREET, BRGY. TINAGO, BAYAWAN CITY,

5. PLACE OF BIRTH BAYAWAN, NEGROS ORIENTAL
NEGROS ORIENTAL
6. SEX Male Female
7. CIVIL STATUS 6221
Single Widowed ZIP CODE

Married Separated 17. TELEPHONE NO. (035)430-0983

Annulled Others, specify ___________ 18. PERMANENT ADDRESS
1175 PEPING GAMO STREET, BRGY. TINAGO, BAYAWAN CITY,
8. CITIZENSHIP FILIPINO
NEGROS ORIENTAL
9. HEIGHT (m) 1.48 m
10. WEIGHT (kg) 44 KG. ZIP CODE 6221
11. BLOOD TYPE O 19. TELEPHONE NO. (035) 430-0983
12. GSIS ID NO. 20. E-MAIL ADDRESS (if any) CAGERMYRA@YAHOO.COM
13. PAG-IBIG ID NO. 0764 546147 11 21. CELLPHONE NO. (if any) 09151129242
14. PHILHEALTH NO. 12-050344626-5 22. AGENCY EMPLOYEE NO.

15. SSS NO. 07-3304410-0 23. TIN 932-564-339

II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME TITO 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME CRISBAL IZZU PENIEL M. TITO 02/07/2004

MIDDLE NAME GERSAN JNANA YUMNA M. TITO 05/09/2012
OCCUPATION UTILITY 1 / /
EMPLOYER/BUS. NAME BAYAWAN DISTRICT HOSPITAL / /
BUSINESS ADDRESS BRGY. UBOS, BAYAWAN CITY / /
TELEPHONE NO. / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME MAGLANGIT / /
FIRST NAME JUAN / /
MIDDLE NAME OMPOC / /
27. MOTHER'S MAIDEN NAME / /
SURNAME TENORIO / /
FIRST NAME VIOLETA / /
MIDDLE NAME TAMPIOC (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR

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

(if graduated)
ELEMENTARY BAYAWAN EAST CENTRAL SCHOOL 1992 1986 1992 WITH HONORS

SECONDARY SAINT AUGUSTINE ACADEMY 1995 1992 1995

VOCATIONAL /

TRADE
COLLEGE
COURSE BACHELOR OF BUSINESS
SILLIMAN UNIVERSITY ADMINISTRATION 2000 1995 2000

MAJOR IN
MANAGEMENT
GRADUATE STUDIES

(Continue on separate sheet if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE
CAREER SERVICE PROFESSIONAL NEGROS ORIENTAL HIGH SCHOOL,
81.06% 03/09/2008 127713 6/19/2008
ELIGIBILITY DUMAGUETE CITY

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
RURAL BANK OF BAYAWAN
03 / 15 /10 02 / 26 /16 BOOKKEEPER 16,500.00 REGULAR NO
(NEG.OR.),INC.
PRIMEASIA PAWN & JEWELRY SHOP,
05 / 01 /03 09 / 15 /09 APPRAISER/CASHIER 8,500.00 REGULAR NO
INC.
BAYAWAN COMMUNITY
10 / 01 /01 04/ 15 /03 SECRETARY-BOD 4,000.00 NO
COOPERATIVE

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(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
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From 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 NUMBER OF CONDUCTED/ SPONSORED BY
in full) (mm/dd/yyyy) HOURS (Write in full)
From To

/ / / /

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(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

TIME MANAGEMENT SKILLS

COMPUTER LITERACY SKILLS

CLERICAL

(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): YES / NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _____________________________________
appointed? _____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________
37 a. Have you ever been formally charged? YES NO
If YES, give details:
________________________________
________________________________
b. Have you ever been guilty of any administrative offense? YES NO
If YES, give details:
________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES NO
regulation by any court or tribunal? If YES, give details:
________________________________
________________________________
39. Have you ever been separated from the service in any of the following modes: resignation, YES NO
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:
________________________________
________________________________

40. Have you ever been a candidate in a national or local election (except Barangay election)? 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? YES NO

If YES, please specify: ____________________
b. Are you differently abled? YES NO
If YES, please specify: ____________________
c. Are you a solo parent? YES NO
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

ATTY. TELESFORO Y. DIAO, JR. DUMAGUETE CITY ID picture taken within

the last 6 months
ROLAND M. REYES BRGY. TINAGO, BAYAWAN CITY 3.5 cm. X 4.5 cm
(passport size)

Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines.

I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential. PHOTO

37159256
COMMUNITY TAX CERTIFICATE NO.

BAYAWAN CITY, NEGROS ORIENTAL

ISSUED AT SIGNATURE (Sign inside the box)

07/07/2016 10/01/2016
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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