CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15336402

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 BELSONDRA
FIRST NAME SIM
MIDDLE NAME ALBAR 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS 3878 REQUINA VILLAGE, P4 JOHN BOSCO,

4. DATE OF BIRTH (mm/dd/yyyy) 05 / 04 / 1982
MANGAGOY, CITY OF BISLIG, SURIGAO DEL SUR
5. PLACE OF BIRTH Mangagoy
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 8311
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS 3878 REQUINA VILLAGE, P4 JOHN BOSCO,
MANGAGOY, CITY OF BISLIG, SURIGAO DEL SUR
8. CITIZENDSHIP FILIPINO
9. HEIGHT (m)

10. WEIGHT (kg) 75 ZIP CODE 8311

11. BLOOD TYPE B+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) simpathetico@gmail.com

13. PAGIBIG ID NO. 1830-0025-3953 21. CELLPHONE NO. (if any) 09077342570
14. PHILHEALTH NO. 18-050028527-1 22. AGENCY EMPLOYEE NO.

15. SSS NO. 33-7598813-9 23. TIN 216-630-941

II. FAMILY BACKGROUND

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

FIRST NAME ROVELYN MERRY MELODY S. BELSONDRA 09 / 18 / 2010

MIDDLE NAME SASIL SIENNA ARIA S. BELSONDRA 11 / 27 / 2016

OCCUPATION SECONDARY SCHOOL TEACHER I

EMPLOYER/BUS. NAME DEPED BISLIG CITY DIVISION

BUSINESS ADDRESS MANGAGOY, BISLIG CITY

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME BELSONDRA

FIRST NAME SUTIMCO

MIDDLE NAME TANTOY

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME ALBAR

FIRST NAME EVELYN

MIDDLE NAME BAGANTE

III. EDUCATIONAL BACKGROUND

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

DE LA SALLE JOHN BOSCO 1988-06- 1995-03-

ELEMENTARY 1995
COLLEGE 10 30

DE LA SALLE JOHN BOSCO 1995-06- 1999-04-

SECONDARY 1999
COLLEGE 10 04
RADIO AND
VOCATIONAL/ TRADE DE LA SALLE JOHN BOSCO 1999-06- 2001-04- TESDA PESFA
TELEVISION 2001
COURSE COLLEGE 10 01 SCHOLAR
TECHNOLOGY
DE LA SALLE JOHN BOSCO COMPUTER 2004-06- 2005-03-
COLLEGE TECHNOLOGY 10 30
BACHELOR OF
SAINT FRANCIS XAVIER 2006-06- 2006-10-
COLLEGE SCIENCE IN
COLLEGE 10 27
ACCOUNTANCY

BELSONDRA, SIM ALBAR - T15336402 CS FORM 212 (Revised 2005), Page 1 of 4

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

BACHELOR OF
SAINT FRANCIS XAVIER 2009-06- 2010-03-
SCIENCE IN OFFICE
COLLEGE 10 30
ADMINISTRATION
BACHELOR OF
SAINT JOSEPH INSTITUTE OF 2010-06- 2014-03-
SCIENCE IN BUSINESS 2014
TECHNOLOGY 10 31
ADMINISTRATION
UNIVERSITY OF BACHELOR OF
2017-08- 2017-12- STEP UP
SOUTHEASTERN SECONDARY 2017
01 23 SCHOLAR
PHILIPPINES - TAGUM EDUCATION (TCP)
SOUTHERN BACHELOR OF
2016-11- 2017-03-
TECHNOLOGICAL INSTITUTE SECONDARY
03 30
OF THE PHILIPPINES EDUCATION
SURIGAO DEL SUR STATE MASTER IN BUSINESS 2018-06-
GRADUATE STUDIES 9 Present
UNIVERSITY ADMINISTRATION 10

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

CS SUB-PROFESSIONAL 81.13 07 / 04 / 2001 CSC REGION IV 01-004512 07/04/2001

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

MOTHER OF MERCY
06/01/2018 SENIOR HIGH SCHOOL TEACHER ACADEMY - BAROBO, SURIGAO 7000 0-0 CONTRACTUAL No
DEL SUR

KING MULTIPURPOSE
09/18/2017 05/31/2018 BRANCH MANAGER 17,000 0-0 CONTRACTUAL No
COOPERATIVE

RADIOWEALTH FINANCE
11/23/2015 09/09/2017 FIELD SALES SUPERVISOR 15,600 0-0 PERMANENT No
COMMPANY

PUBLIC SAFETY MUTUAL

05/25/2015 10/23/2015 FIELD OFFICER PRO 13 10,500 0-0 PROBATIONARY No
BENEFIT FUND

08/11/2014 01/28/2015 TRAINING ASSISTANT SURSECO I 6,000 0-0 CONTRACTUAL No

08/08/2010 12/31/2011 CLERK / IT STAFF LGU BISLIG CITY 5,000 0-0 JOB ORDER Yes

02/15/2005 07/12/2010 BRANCH MANAGER TMA LENDING CORPORATION 10,000 0-0 PERMANENT No

05/25/2002 02/15/2005 COMMUNICATION SPECIALIST TMA LENDING CORPORATION 3,500 0-0 PERMANENT No

SAN BENILDO INTEGRATED

05/05/2001 03/10/2002 INSTITUTIONAL TECHNICIAN 7,500 0-0 CONTRACTUAL No
SCHOOL

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

BAROBO HOMEOWNER'S ASSOCIATION 2018-08-01 Present BOARD OF DIRECTOR

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

TANDAG DIOCESAN
TADICSA EDUCATOR'S ASSEMBLY 11 / 21 / 2018 11 / 24 / 2018 16 CATHOLIC SCHOOLS
ASSOCIATION (TADICSA)
SURIGAO DEL SUR STATE
TOURISM: A LIVELIHOOD OPPORTUNITY & TIPS ON HOW TO
09 / 15 / 2018 09 / 15 / 2018 4 UNIVERSITY - MAIN CAMPUS,
HANDLE YOUR FINANCES (MORNING SESSION
TANDAG CITY
SURIGAO DEL SUR STATE
EFFECTIVE EMPLOYEE RETENTION SEMINAR WORKSHOP
09 / 15 / 2018 09 / 15 / 2018 4 UNIVERSITY - MAIN CAMPUS,
(AFTERNOON SESSION)
TANDAG CITY

BELSONDRA, SIM ALBAR - T15336402 CS FORM 212 (Revised 2005), Page 2 of 4

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

CATHOLIC EDUCATION
ASSOCIATION OF THE
CEAP REGIONAL ASSEMBLY 09 / 14 / 2018 09 / 14 / 2018 8
PHILIPPINES - CARAGA
REGION
COOPERATIVE UNION OF
GENDER SENSITIVITY SEMINAR 11 / 15 / 2017 11 / 15 / 2017 8
DAVAO CITY

BUSINESS PLANNING 10 / 24 / 2017 10 / 26 / 2017 24 NATCCO NETWORK

BASIC SEMINAR WORKSHOP FOR ENGAGING AND EMPOWERING

10 / 07 / 2017 10 / 07 / 2017 8 STEP UP PHILIPPINES
TEACHERS TO BE (SWEET I)

UNIVERSITY OF
OBSERVATION OF LEARNER'S DEVELOPMENT AND SCHOOL
09 / 04 / 2017 12 / 22 / 2017 20 SOUTHEASTERN
ENVIRONMENT (FS 1)
PHILIPPINES - TAGUM CITY
UNIVERSITY OF
ON BECOMING A TEACHER (FS 6) 09 / 04 / 2017 12 / 22 / 2017 20 SOUTHEASTERN
PHILIPPINES - TAGUM CITY
UNIVERSITY OF
ASSESSMENT FOR STUDENT LEARNING (FS 5) 09 / 04 / 2017 12 / 22 / 2017 20 SOUTHEASTERN
PHILIPPINES - TAGUM CITY
UNIVERSITY OF
CLASSROOM MANAGEMENT SKILLS IN THE TEACHING LEARNING
09 / 04 / 2017 12 / 22 / 2017 20 SOUTHEASTERN
PROCESS (FS 2)
PHILIPPINES - TAGUM CITY
UNIVERSITY OF
MICRO TEACHING AND THE USE OF TECHNOLOGY (FS 3) 09 / 04 / 2017 12 / 22 / 2017 20 SOUTHEASTERN
PHILIPPINES - TAGUM CITY
UNIVERSITY OF
TEAM TEACHING: EXPLORING THE CURRICULUM (FS 4) 09 / 04 / 2017 12 / 22 / 2017 20 SOUTHEASTERN
PHILIPPINES - TAGUM CITY

BASIC SEMINAR WORKSHOP FOR ENGAGING AND EMPOWERING

09 / 01 / 2017 09 / 01 / 2017 8 STEP UP PHILIPPINES
TEACHERS TO BE (SWEET)

RADIOWEALTH FINANCE
FUNDAMENTALS OF CREDIT AND MANAGEMENT 04 / 13 / 2016 04 / 15 / 2016 24
COMPANY, INC.
INTERNATIONAL COMMITTEE
PERFORMANCE ENHANCEMENT 12 / 03 / 2013 12 / 03 / 2013 8 OF THE RED CROSS (ICRC)
PHILS.
PHILIPPINE RED CROSS -
FIRST AID TRAINING IN THE WORKPLACE 07 / 24 / 2013 07 / 24 / 2013 8
MATI CHAPTER
INTERNATIONAL COMMITTEE
WORKING IN THE ICRC COURSE 02 / 21 / 2013 02 / 22 / 2013 16 OF THE RED CROSS (ICRC)
PHILS.
DE LA SALLE JOHN BOSCO
ON-THE-JOB TRAINING 02 / 01 / 2001 04 / 01 / 2001 200
COLLEGE

DE LA SALLE JOHN BOSCO

WEBPAGE DESIGNING SEMINAR WORKSHOP 01 / 27 / 2001 01 / 27 / 2001 8
COLLEGE

IN-PLANT TRAINING PROGRAM 11 / 07 / 2000 02 / 15 / 2001 200 PICOP RESOURCES INC.

2ND SURIGAO DEL SUR PROVINCIAL SKILLS COMPETITION 09 / 27 / 2000 09 / 28 / 2000 16 TESDA PROVINCIAL

VIII. OTHER INFORMATION

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

1993 MUSIC FESTIVAL CHAMPION - VOCAL SOLO -

SINGING BUKAS PALAD ONLINERS COMMUNITY
DEPENDENT CATEGORY

CHAMPIONS IN DIFFERENT CHOIR COMPETITION IN CARAGA

CHOIR CONDUCTING CHOIRMASTER - CORO DE OASIS OF LOVE
REGION

CHOIRMASTER - SAINT VINCENT DE PAUL

GUITAR AND PIANO PLAYING
PARISH LITURGICAL MUSIC MINISTRY

COMPUTERS AND INFORMATION CHOIRMASTER - STO. TOMAS DE

TECHNOLOGY VILLANUEVA CHORALE

BOARD OF DIRECTOR - BAROBO

TEACHING
HOMEOWNER'S ASSOCIATION

CHOIR MUSIC WRITING AND ARRANGING

BELSONDRA, SIM ALBAR - T15336402 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
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:
FINISHED CONTRACT

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.

LUTHER O. PONCE TANDAG CITY, SURIGAO DEL SUR 09102014706

MYRNA E. MOZO BAROBO, SURIGAO DEL SUR 09308684124

ANTONIETA O. NARRA CABADBARAN CITY, AGUSAN DEL

NORTE
09483180400

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

17677363

COMMUNITY TAX CERTIFICATE NO.

BAROBO, SURIGAO DEL SUR

ISSUED AT SIGNATURE (Sign inside the box)

2019-01-16 01 / 24 / 2019

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

BELSONDRA, SIM ALBAR - T15336402 CS FORM 212 (Revised 2005), Page 4 of 4