CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "

1. CS ID No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
C | A | R | I | N |G |A

2. SURNAME

|L

FIRST NAME

C| R | I | S | A | B | E | L |

MIDDLE NAME

L | O | P | E | Z |

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40-11th Ave., Cubao, Quezon City

5. PLACE OF BIRTH

Male

6. SEX
7. CIVIL STATUS

Married

Separated

Annulled

Others, specify _________ 18. PERMANENT ADDRESS

9. HEIGHT (m)

1.67

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

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Fem ale
Widowed

FILIPINO

#1068 MALABANBAN SUR, CANDELARIA, QUEZON

Single

8. CITIZENSHIP

16. RESIDENTIAL ADDRESS

11/26/1971

4. DATE OF BIRTH (mm/dd/yyyy)

ZIP CODE

4323

17. TELEPHONE NO.

#1068 MALABANBAN SUR, CANDELARIA, QUEZON

10. WEIGHT (kg)

70

11. BLOOD TYPE

B+

19. TELEPHONE NO.

12. GSIS ID NO.

02003922940

20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO.

1460- 0043- 4276

21. CELLPHONE NO. (if any)

0916-6546257

14. PHILHEALTH NO.

08-000087331-8

22. AGENCY EMPLOYEE NO.

4268713

23. TIN

259-747-266

ZIP CODE

15. SSS NO.

4323
None

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME

CARINGAL

25. NAME OF CHILD (Write full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

JANOEL GLEN L. CARINGAL

01/24/1993

CARINGAL

NICOLE L. CARINGAL

11/18/1994

OCCUPATION

WELDER

GEROME L. CRINGAL

11/26/1997

EMPLOYER/BUS. NAME

NONE

JOSHUA JAMES L. CARIMGAL

05/08/2000

BUSINESS ADDRESS

NONE

JUSTIN L. CARINGAL

01/04/2005

TELEPHONE NO.

NONE

IRISH YSABEL L. CARINGAL

01/03/2015

FIRST NAME

NOEL

MIDDLE NAME

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME

LOPEZ

FIRST NAME

ABELARDO

MIDDLE NAME

GONZAGA

27. MOTHER'S MAIDEN NAME

SURNAME

FLORES

FIRST NAME

CRISPINA

MIDDLE NAME

DE CASTRO (deceased)

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

UNITS EARNED
(if not graduated)

full)

ELEMENTARY

SAN FRANCISCO ELEMENTARY SCHOOL

ELEMENTARY

SECONDARY
VOCATIONAL /

TAYABAS WESTERN ACADEMY

TAYABAS WESTERN ACADEMY

COLLEGE
COURSE

HIGHEST GRADE/
LEVEL/

DEGREE COURSE
(Write in full)

(if graduated)

INCLUSIVE DATES OF
ATTENDANCE
From

To

1984

GRADUATED

1978

1984

SECONDARY

1988

GRADUATED

1984

1988

BACHELOR OF
SECONDARY EDUCATION

2000

GRADUATED

1988

2000

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

TRADE

MANUEL S. ENVERGA UNIVERSITY

FOUNDATION, INC.

15 UNITS IN
GEN. SCIENCE

2003

GRADUATE STUDIES

(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

Licensure Examination for Teachers

LICENSE (if applicable)

RATING

DATE OF
EXAMINATION /
CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

75.00%

08/21/2001

LUCENA CITY

NUMBER

DATE OF
RELEASE

0710176

10/26/2001

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.

INCLUSIVE DATES
(mm/dd/yyyy)
From

To

03/04/2008

to date

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

(Write in full)

GOV'T
SERVICE
MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT

(Yes / No)

Secondary School Teacher I

DepEd Manuel Macasaet National High

School

Php
18,922.00

11-03

Permanent

09/18/2006 01/03/2008

Secondary School Teacher I

Manuel Macasaet National High School

(Locally Funded)

Php
6,500.00

N/A

Casual

Yes

06/21/2004 12/16/2005

Secondary School Teacher I

Padre Garcia NHS (Locally Funded)

Php 5,000

N/A

Casual

Yes

09/01/2001 10/31/2001

Substitute Teacher

Tayabas Western Academy

Php 8,000

N/A

Temporary

No

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

INCLUSIVE DATES
(Write in full)

(mm/dd/yyyy)
From

NUMBER OF
HOURS

POSITION / NATURE OF WORK

N/A

N/A

To

NONE

(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

in full)

NUMBER OF
HOURS

(mm/dd/yyyy)

CONDUCTED/ SPONSORED BY
(Write in full)

From

To

K-12 Mass Training for Grade 10 Teachers

5/17/2015

5/22/2015

48

Manuel S. Enverga University

Foundation

Seminar Workshop fo High School Teachers on

Strengthening the Classroom Approach in Teaching
Selected Topics in Mathematics

4/21/2014

4/23/2014

24

UPLB College of Arts, Institute

of Mathematical Sciences and
Physics

SEMINAR WORKSHOP ON SCHOOL GOVERNANCE

2/13/2014

2/14/2014

16

DepEd-Division of Quezon

Cluster VII Orientation Workshop on the Use of

Revised SBM Assessment Process and Tools (APAT)

4/16/2013

4/17/2013

16

DepEd-Division Quezon
(Cluster)

Summer Institute of Cluster IV

5/28/2012

5/30/2012

24

DepEd- Division of Quezon (Cluster)

Division Training Workshop on ICT Integration in

Teaching Secondary Mathematics

11/26/2011

11/27/2011

16

DepEd- Division of Quezon

Implementation of the Competency-Based

Performance Appraisal System for Teachers (CBPAST)

4/13/2011

4/14/2011

16

DepEd- Division of Quezon

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

33.

SPECIAL SKILLS / HOBBIES:

Computer Literate (basic)

34.

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

(Write in full)

None

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in
full)

None

Baking

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):

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
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

b.

Within the fourth degree (for Local Government Employees):

appointing authority or recommending authority where you will be appointed?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37

a. Have you ever been formally charged?

If YES, give details:
________________________________
________________________________
YES

b. Have you ever been guilty of any administrative offense?

NO

If YES, give details:

________________________________
________________________________
38.

39.

40.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?

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

NO

If YES, give details:

________________________________
________________________________

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?

b.

Are you differently abled?

c.

Are you a solo parent?

YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME

ADDRESS

TEL. NO.

Mrs. Nilda P. Abulencia

Cotta, Lucena City

585-4989

Ricardo V. Lagrosa

Ramos St., Candelaria, Quezon

9077862203

Brgy. Capt. Edna Macapugay

Malabanban Sur, Candelaria, Quezon

585-6719

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.

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

PHOTO

29143321
COMMUNITY TAX CERTIFICATE NO.

Candelaria, Quezon
ISSUED AT

SIGNATURE (Sign inside the box)

01/06/2015

07/31/2015

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK

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