CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15155226

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 TABIOLO
FIRST NAME HENRY
MIDDLE NAME GEVA 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS ROXAS STREET,BRGY.ROBLES, LA CASTELLANA,

4. DATE OF BIRTH (mm/dd/yyyy) 09 / 12 / 1979
NEGROS OCCIDENTAL
5. PLACE OF BIRTH LA CASTELLANA, NEG.OCC.
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 6131
Married Separated
17. TELEPHONE NO. 09214954035
Annuled Others, specify
_________ 18. PERMANENT ADDRESS ROXAS STREET, BRGY.ROBLES, ,

8. CITIZENDSHIP FILIPINO
9. HEIGHT (m) 155
10. WEIGHT (kg) 97 ZIP CODE 6131
11. BLOOD TYPE A+ 19. TELEPHONE NO. 09214954035
12. GSIS ID NO. 003-3902-8795-4 20. EMAIL ADDRESS (if any) henrytabiolo@yahoo.com
13. PAGIBIG ID NO. 110001105906 21. CELLPHONE NO. (if any) 09214954035
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 33-9028795-4 23. TIN 943502868

II. FAMILY BACKGROUND

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

FIRST NAME EVEROSE

MIDDLE NAME LUMANAG

OCCUPATION TEACHER

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME TABIOLO

FIRST NAME DOMINGO

MIDDLE NAME TACUYAN

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME GEVA

FIRST NAME NANCY

MIDDLE NAME GALOR

III. EDUCATIONAL BACKGROUND

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

AGUSTINA,ELEMENTARY 1986-06- 1992-03-

ELEMENTARY 1992
SCHOOL 05 28

SECONDARY ST'S.VINCENT HIGH SCHOOL 1996 1992 1996

VOCATIONAL/ TRADE
2001
COURSE

NEGROS OCCIDENTAL
COLLEGE BS AGRICULTURE 2001 1997 2001
AGRICULTURAL COLLEGE

SUPPLEMENTAL UNIT
WEST NEGROS COLLEGE 2001 2002
IN EDUCATION

TABIOLO, HENRY GEVA - T15155226 CS FORM 212 (Revised 2005), Page 1 of 3

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

CENTRAL PHILIPPINE STATE

GRADUATE STUDIES MA ED. 42 2010 2012
UNIVERSITY

IV. CIVIL SERVICE ELIGIBILITY

29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE

TEACHERS EXAM 75 08 / 25 / 2002 ILO ILO 0783174 09/12/1996

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

11/15/2007 05/01/2016 TEACHER-II DEP.ED 21,940.00 12 - 0 REG/PER. Yes

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

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

DEP.ED. 06 / 06 / 2002 07 / 19 / 2004 VOLUNTEER TEACHER

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

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

ORGANIC AGRICULTURE NC-II 02 / 04 / 2016 02 / 05 / 2016 16 TESDA

TRAINERS METHODOLOGY CERTIFICATE I 12 / 09 / 2015 12 / 10 / 2015 16 TESDA

ANIMAL PRODUCTION NC-II 04 / 01 / 2015 04 / 02 / 2015 16 TESDA

HORTICULTURE NC-II 07 / 25 / 2014 07 / 27 / 2014 24

VIII. OTHER INFORMATION

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

GARDENING,DRIVING,COMP.LIT.

TABIOLO, HENRY GEVA - T15155226 CS FORM 212 (Revised 2005), Page 2 of 3

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
has immediate supervision over you in the Office, Bureau or Department where you will be If YES, give details:
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.

MA.TRESSA G. ELBANBUENA LA CASTELLANA NATIONAL HIGH 09189330283

SCOOL
JOY O. ESTACION GUINPANA-AN NATIONAL HIGH
SCOOL
MELMAR H. LACSON LA CASTELLANA NATIONAL HIGH
SCOOL
09989735260

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

16214269

COMMUNITY TAX CERTIFICATE NO.

LA CASTELLANA

ISSUED AT SIGNATURE (Sign inside the box)

06 / 05 / 2016

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

TABIOLO, HENRY GEVA - T15155226 CS FORM 212 (Revised 2005), Page 3 of 3