CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes [ ] with "/" and use separate sheet if necessary 1. CS ID. NO.
I. PERSONAL INFORMATION
2. SURNAME G R A G A S I N
FIRST NAME S H I R L E Y
MIDDLE NAME A F A G A 3. NAME EXTENSION (e.g. Jr., Sr.) NONE
4. DATE OF BIRTH (mm/dd/yyyy) 1/25/1980 16. RESIDENTIAL ADDRESS
5. PLACE OF BIRTH CALAMAGUI I, ILAGAN CITY PUROK 07 LINAMANAN, JONES, ISABELA
6. SEX [ ] Male [ / ] Female
[ ] Single [ ] Widow ZIP CODE 3313
7. CIVIL STATUS [ / ] Married [ ] Separated 17. TELEPHONE NO. NONE
[ ] Annuled [ ] Others ______ 18. PERMANENT ADDRESS
8. CITIZENSHIP FILIPINO PUROK 07 LINAMANAN, JONES, ISABELA
9. HEIGHT (m) 1.66 m
10. WEIGHT (kg) 63 kg ZIP CODE 3313
11. BLOOD TYPE B 19. TELEPHONE NO. NONE
12. GSIS IS NO. 2004294649 20. E-MAIL ADDRESS (if any) SHIRLEY_A_GRAGASIN@yahoo.com
13. PAG-IBIG I.D. NO. 20139369802 21. CELLPHONE NO. (if any) 9064960869
14. PHILHEALTH NO. 19-089659591-2 22. AGENCY EMPLOYEE NO. 4025
15. SSS. NO. 33-7119989-6 23. TIN 207-187-894-0
II. FAMILY BACKGROUND
24. SPOUSES SURNAME GRAGASIN 25. NAME OF CHILD (Write full name & list all) DATE OF BIRTH (mm/dd/yyy)
FIRST NAME MICHAEL MICHAEL PSALM A. GRAGASIN 7 30 2010
MIDDLE NAME BACENA DARLENE GRACE A. GRAGASIN 9 25 2013
OCCUPATION TEACHING
EMPLOYER/BUS. NAME LINAMANAN ELEM. SCHOOL
BUSINESS ADDRESS LINAMANAN, JONES, ISABELA
TELEPHONE NO. NONE
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME AFAGA (DECEASED)
FIRST NAME ARGELITO
MIDDLE NAME LORENZO
27. MOTHERS MAIDEN NAME
SURNAME DOMINGO (DECEASED)
FIRST NAME ZENAIDA
MIDDLE NAME TADEO (continue separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST INCLUSIVE DATES SCHOLARSHIP
28. LEVEL NAME OF SCHOOL DEGREE YEAR GRADE/LEVEL UNITS OF ATTENDANCE ACADEMIC HONORS
(Write Full) COURSE GRADUATED EARNED From To
(Write full) (if not graduated)
ELEMENTARY CALINAOAN GRADES 1992 GRADUATED 1986 1992 NONE
ELEMENTARY SCHOOL SCHOOL
SECONDARY NORTHERN ISABELA HIGH 1996 GRADUATED 1992 1996 FIFTH HONORABLE
ACADEMY SCHOOL MENTION
VOCATIONAL TRADE NONE NONE NONE NONE NONE NONE NONE
COURSE
ISABELA COLLEGES COMPUTER 1999 GRADUATED 1997 1999 ACADEMIC
COLLEGE SECRETARIAL SCHOLAR
PHILIPPINE NORMAL BSE MAJOR IN 2006 GRADUATED 2002 2006 LEADERSHIP AWARD
UNIVERSITY ENGLISH
ISABELA COLLEGES MASTER OF ARTS NOT 33 2006 2007 NONE
GRADUATES IN EDUCATION APPLICABLE
STUDIES NORTHEASTERN MASTER OF ARTS
COLLEGE IN EDUCATION 2016 GRADUATED 2013 2016 DIPLOMA

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Pae 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. CAREER SERVICE/RA 1080 DATE OF
(BOARD/BAR) UNDER SPECIAL RATING EXAMINATION/CONFERMENT PLACE OF EXAMINATION/CONFERMENT LICENSE (if applicable)
LAW/CES/CSEE NUMBER DATE OF RELEASE
LICENSE EXAMINATION FOR 78.40% August 27, 2006 TUGUEGARAO, CAGAYAN PRC 0938702 10/7/2006
TEACHERS (LET)

(Continue separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from current work)
30. INCLUSIVE DATES DEPARTMENT/AGENCY/ SALARY GRADE STATUS OF GOVT
(mm/dd/yyyy) POSITION OFFICE/COMPANY MONTHLY & STEP APPOINTMENT SERVICE
FROM TO (Write in Full) (Write in Full) SALARY INCREMENT (Yes/No)
8/24/2016 PRESENT TEACHER I LINAMANAN ELEMENTARY SCHOOL Php 18,549.00 11 PERMANENT YES
6/5/2015 8/23/2015 TEACHER III AGLIPAY HIGH SCHOOL Php 21,436.00 13 PERMANENT YES
1/4/2013 6/4/2015 TEACHER I AGLIPAY HIGH SCHOOL Php 18,549.00 11 PERMANENT YES
9/1/2012 12/31/2012 OFFICE CLERK AGLIPAY HIGH SCHOOL Php 7,500.00 NOT APPLICABLE CASUAL YES
7/1/2012 8/31/2012 TEACHER I JONES WEST DISTRICT SCH. CAMPUS 2 Php 15,694.00 11 SUBSTITUTE YES
1/3/2012 3/30/2012 TEACHERS I AGLIPAY HIGH SCHOOL Php 7,500.00 NOT APPLICABLE CASUAL YES
6/6/2011 12/31/2011 TEACHER I AGLIPAY HIGH SCHOOL Php 15,694.00 11 SUBSTITUTE YES
CLASSROOM CENTRAL ISABELA CHRISTIAN
6/11/2008 3/31/2010 TEACHER ACADEMY Php 7,500.00 NOT APPLICABLE REGULAR NO
ENGLISH UNIVERSITY OF MANILA - INTERNATIONAL
7/2/2007 10/30/2007 TEACHER LANGUAGE SCHOOL Php 8,000.00 NOT APPLICABLE PROBATIONARY NO
CLASSROOM MERRY SUNSHINE MONTESSORI
6/3/2006 4/5/2007 TEACHER SCHOOL Php 5,500.00 NOT APPLICABLE PROBATIONARY NO

(Continue separate sheet if necessary)

CS FORM 212 (Revised 2005), Pae 2 of 4
VI. VOLUNTARY WORK OR INVOLEMENT IN CIVIC/NON-GOVERNMENT/PEOPLE/VOLUNTARY ORGANIZATION/S
31. NATURE AND ADDRESS OF ORGANIZATION INCLUSIVE DATES (mm/dd/yyyy) NUMBER CONDUCTED/SPONSORED BY
(Write in Full) From To OF HOURS (Write in Full)
BRIGADA ESKWELA 5/23/2013 5/26/2013 40 DepEd-AGLIPAY HIGH SCHOOL
BRIGADA ESKWELA 5/26/2014 5/30/2014 40 DepEd-AGLIPAY HIGH SCHOOL
DAILY VACATION BIBLE SCHOOL (DVBS) 5/6/2014 5/8/2014 16 CHURCH OF GOD-LINAMANAN, JONES
BRIGADA ESKWELA 5/18/2014 5/22/2014 40 DepEd-AGLIPAY HIGH SCHOOL
BRIGADA ESKWELA 5/18/2015 5/22/2015 40 DepEd-AGLIPAY HIGH SCHOOL
NATIONAL WORSHIP CAMP 2016 4/23/2016 4/27/2016 40 CHURCH OF GOD-DASMARIṄAS, CAVITE

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

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOPS/SHORT COURSES INCLUSIVE DATES (mm/dd/yyyy) NUMBER CONDUCTED/SPONSORED BY
(Write in Full) From To OF HOURS (Write in Full)
DISTRICT FOLLOW-THROUGH TRAINING OF WRITERS ON
LOCAL HISTORY WRITING IN ARALING PANLIPUNAN 2 3/22/2016 3/23/2016 16 DepEd - JONES WEST DISTRICT
DIVISION TRAINING OF WRITERS ON LOCAL HISTORY WRITING
IN ARALING PANLIPUNAN 2 3/15/2016 3/16/2016 18 DepEd - DIVISION OFFICE
DIVISION SCHOOLS PRESS CONFERENCE 11/21/2016 11/23/2016 24 DepEd - DIVISION OFFICE
DISTRICT SCHOOLS PRESS CONFERENCE 11/20/2015 11/20/2015 8 DepEd - JONES WEST DISTRICT
2015 DISTRICT KAB AND STAR PALABAS 11/13/2015 11/13/2015 8 DepEd - JONES WEST DISTRICT
SCHOOL LEARNING ACTION CELL (SLAC) 9/30/2015 9/30/2015 8 DepEd - JONES WEST DISTRICT
NATIONAL TRAINING/SEMINAR/WORKSHOP ON
PHIL. PROFESSIONAL LINKAGES FROM
CAMPUS JOURNALISM 7/31/2015 8/2/2015 24 VARIOUS DISCIPLINES INC.
SCHOOL-BASED IN-SERVICE TRAINING 5/25/2015 5/27/2015 24 AGLIPAY HIGH SCHOOL, AGLIPAY QUIRINO
REGIONAL TRAINING OF GRADE 10 ENGLISH TEACHERS
OF THE K TO 12 5/6/2015 5/11/2015 48 DepEd-TEACHERS EDUCATION COUNCIL
EDUCATION SUMMIT 4/27/2015 4/27/2015 8 DepEd-DIVISION OF QUIRINO
FIRE PREVENTION MONTH 2015 3/6/2015 3/6/2015 4 BUREAU OF FIRE PROTECTION - AGLIPAY
REGIONAL SCHOOLS PRESS CONFERENCE 1/7/2015 1/10/2015 32 DepEd REGION 02
LINGGO NG KABATAAN 12/25/2014 12/27/2014 24 BRGY. LINAMANAN, JONES, ISABELA
DIVISION CRITIQUING AND WRITESHOP FOR 2015 RSPC QUALIFIERS 12/17/2014 12/18/2014 16 DepEd-DIVISION OF QUIRINO
SCHOOL-BASED BSP/GSP ENCAMPMENT 11/27/2014 11/29/2014 24 AGLIPAY HIGH SCHOOL, AGLIPAY QUIRINO
INFORMATION DRIVE ON THE RISK TAKING
BEHAVIOR OF TEEN AGERS 11/28/2014 11/28/2014 4 AGLIPAY HIGH SCHOOL, AGLIPAY QUIRINO
2014 DIVISION SCHOOLS PRESS CONFERENCE 11/21/2014 11/22/2014 16 DepEd-DIVISION OF QUIRINO
SCHOOL-BASED IN-SERVICE TRAINING ON TEACHERS DEV'T 11/20/2014 10/24/2014 40 AGLIPAY HIGH SCHOOL, AGLIPAY QUIRINO
SECOND NATIONAL LEADERSHIP TRAINING PHIL. CENTER OF EXCELLENCE FOR
10/17/2014 10/19/2014 24 PROFESSIONAL ADVANCEMENT

VIII. OTHER INFORMATION

33. SPECIAL SKILLS/HOBBIES 34. NON-ACADEMIC DISTINCTION/RECOGNITION
(Write in Full)
SINGING
WRITING/ NEWSPAPERING
CERTIFICATE OF RECOGNITION-FIRST PLACE IN
WORKING WITH COMPUTERS USING COLLABORATIVE AND DESKTOP PUBLISHING
MICROSOFT SOFTWARES DURING THE 2015 RSPC
CERTIFICATE OF RECOGNITION-FIRST PLACE IN
NEWS WRITING - PAPER ADVISERS' CATEGORY
DURING THE 2015 NATIONAL TRAINING/ SEMINAR/
WORKSHOP ON CAMPUS JOURNALISM
35. MEMBERSHIP IN ASSOCIATION
ORGANIZATION (Write in Full)
NATIONAL ORGANIZATION OF PROFESSIONAL
TEACHERS
PROVINCIAL SECONDARY SCHOOL PAPER
ADVISERS
QUIRINO SCHOOL PAPER ADVISERS
ASSOCIATION

CS FORM 212 (Revised 2005), Pae 3 of 4

36. Are you realated by consanguinity or afinity of the following
a. within the third degree (for Nationa Government Employees): YES / NO
Appointing authority, recommending authority, chief of office/bureau/department or person who has if YES, give details:
immediate supervision over you in the Office, Bureau of Department were 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 regulation by any
court or tribunal YES / NO
if YES, give details:

39. Have you ever been separated from the serice 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 YES / NO
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:
FINISHED CONTRACT

41. Pursuant to (a) Indigenous People 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: YES / NO
if YES, give details:
a. Are you a member of any indingenous group?

b. Are you differently abled? YES / NO

if YES, give details:

c. Are you solo parent? YES / NO

if YES, give details:

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

NAME ADDRESS TEL. NO.
FRANCISCA B. ALCALDE, Ed.D. ZAMORA, CABARROGUIS, QUIRINO 9178377404
JOSEPHINE P. COLLADO GUINALBIN, AGLIPAY, QUIRINO 915860607
CHARITY V. RAMISCAL PROGRESO, AGLIPAY, QUIRINO 9178191732

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 law, 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.

380402
COMMUNITY TAX CERTIFICATE NO.
LINAMANAN, JONES, ISABELA
ISSUED AT SIGNATURE (Sign inside the box)

23-Feb-16 APRIL 05, 2016

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Pae 4 of 4
CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes [ ] with "/" and use separate sheet if necessary 1. CS ID. NO.
I. PERSONAL INFORMATION
2. SURNAME M A N U E L
FIRST NAME O R L A N D O
MIDDLE NAME E S L A V A 3. NAME EXTENSION (e.g. Jr., Sr.)
4. DATE OF BIRTH (mm/dd/yyyy) 05/29/1964 16. RESIDENTIAL ADDRESS PUROK 4, GUNDAWAY
5. PLACE OF BIRTH BAMBANG, NUEVA VIZCAYA CABARROGUIS, QUIRINO
6. SEX [ / ] Male [ ] Female
[ ] Single [ ] Widow ZIP CODE 3400
7. CIVIL STATUS [ / ] Married [ ] Separated 17. TELEPHONE NO. NONE
[ ] Annuled [ ] Others ______ 18. PERMANENT ADDRESS PUROK 4, GUNDAWAY
8. CITIZENSHIP FILIPINO CABARROGUIS, QUIRINO
9. HEIGHT (m) 1.7
10. WEIGHT (kg) 82 ZIP CODE 3400
11. BLOOD TYPE B 19. TELEPHONE NO. 078-6826746
12. GSIS IS NO. CM2410537 20. E-MAIL ADDRESS (if any) oem_lyor_08@yahoo.com
13. PAG-IBIG I.D. NO. 020101028207 21. CELLPHONE NO. (if any) 09272797333
14. PHILHEALTH NO. 06-000006819-8 22. AGENCY EMPLOYEE NO. 120023
15. SSS. NO. NOT APPLICABLE 23. TIN 14-2269835000
II. FAMILY BACKGROUND
24. SPOUSES SURNAME LAPADA 25. NAME OF CHILD (Write full name & list all) DATE OF BIRTH (mm/dd/yyy)
FIRST NAME FELY RYANN STEVENSON L. MANUEL 04 16 1983
MIDDLE NAME LAPADA RYNNA QUINN L. MANUEL 08 11 1985
OCCUPATION HEAD TEACHER III RYDIANT JOY BLESSING L. MANUEL 12 08 1992
EMPLOYER/BUS. NAME DepEd, Cabarroguis., Nat'l SAT
BUSINESS ADDRESS Gundaway Cabarroguis, Quirino
TELEPHONE NO. none
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME MANUEL (DECEASED)
FIRST NAME DAMASO
MIDDLE NAME CRISTOBAL
27. MOTHERS MAIDEN NAME
SURNAME ESLAVA (DECEASED)
FIRST NAME JOSEFA
MIDDLE NAME ONIA (continue separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
HIGHEST INCLUSIVE DATES SCHOLARSHIP
28. LEVEL NAME OF SCHOOL DEGREE YEAR GRADE/LEVEL UNITS OF ATTENDANCE ACADEMIC HONORS
(Write Full) COURSE GRADUATED EARNED From To
(Write full) (if not graduated)
ELEMENTARY BAMBANG WEST Elementary NOT
ELEMENTARY SCHOOL Graduate 1976 APPLICABLE 1970 1976 DIPLOMA
SECONDARY NUEVA VIZCAYA SCHOOL High School NOT First
OF ARTS & TRADES Graduate 1980 APPLICABLE 1976 1980 Honorable Mention
VOCATIONAL TRADE
COURSE
NUEVA VIZCAYA BS Industrial NOT
COLLEGE STATE POLYTHECHNIC Education 1984 APPLICABLE 1980 1984 CUMLAUDE
COLLEGE
NUEVA VIZCAYA Master of NOT
GRADUATES STATE POLYTHECHNIC Arts in Teaching 1990 APPLICABLE 1984 1990 LOYALTY AWARD
STUDIES COLLEGE
Doctor of 2001 NOT 1997 2001 DEAN'S LIST AND
Philosophy APPLICABLE LOYALTY AWARD
 (Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Pae 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/RA 1080 DATE OF
(BOARD/BAR) UNDER SPECIAL RATING EXAMINATION/CONFERMENT PLACE OF EXAMINATION/CONFERMENT LICENSE (if applicable)
LAW/CES/CSEE NUMBER DATE OF RELEASE
PBET 80.64 24-Nov-85 Bayombong, Nueva Vizcaya PRC 0330069 3/19/1998
C.S. Professional 71.60 30-Mar-84 Bayombong, Nueva Vizcaya
P.D. 907 Q 30-Mar-84 NvVSPC, Bambang, Nueva Vizcaya
C.S. Sub-Professional 70 17-Jul-83 Bayombong, Nueva Vizcaya

(Continue separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from current work)
30. INCLUSIVE DATES DEPARTMENT/AGENCY/ SALARY GRADE STATUS OF GOVT
(mm/dd/yyyy) POSITION OFFICE/COMPANY MONTHLY & STEP APPOINTMENT SERVICE
FROM TO (Write in Full) (Write in Full) SALARY INCREMENT (Yes/No)

1/18/2002 present SSP I Cabarroguis National School of Arts & Trades 15,841.00 16-1 Permanent YES
7/1/2001 1/17/2002 Head Teacher III Cabarroguis National School of Arts & Trades 14,680.00 15-5 Permanent YES
1/1/2001 6/30/2001 Head Teacher III Cabarroguis National School of Arts & Trades 13,981.00 15-5 Permanent YES
6/10/1999 12/31/1999 Head Teacher III Cabarroguis National School of Arts & Trades 12,710.00 15-4 Permanent YES
7/1/1998 6/4/1999 Head Teacher III Cabarroguis National School of Arts & Trades 12,400.00 15-4 Permanent YES
11/1/1997 6/30/1998 Head Teacher III Cabarroguis National School of Arts & Trades 12,400.00 15-1 Permanent YES
1/1/1997 10/31/1997 Head Teacher III Cabarroguis National School of Arts & Trades 9,962.00 15-3 Permanent YES
1/1/1996 12/31/1996 Head Teacher III Cabarroguis National School of Arts & Trades 7,826.00 15-3 Permanent YES
1/1/1995 12/31/1995 Head Teacher III Cabarroguis National School of Arts & Trades 6,207.00 15-2 Permanent YES
1/1/1994 12/31/1994 Head Teacher III Cabarroguis National School of Arts & Trades 5,207.00 15-2 Permanent YES
1/1/1993 12/31/1993 Head Teacher III Cabarroguis National School of Arts & Trades 4,507.00 15-1 Permanent YES
7/1/1989 12/31/1992 Head Teacher III Cabarroguis National School of Arts & Trades 4,418.00 15-1 Permanent YES
1/1/1988 6/30/1989 Head Teacher I Cabarroguis National School of Arts & Trades 2,154.00 Permanent YES
6/10/1987 12/31/1987 Head Teacher I Cabarroguis National School of Arts & Trades 1,958.00 Permanent YES
3/1/1987 6/9/1987 Teacher Cabarroguis National School of Arts & Trades 1,604.00 Permanent YES
7/1/1986 2/28/1987 Teacher Cabarroguis National School of Arts & Trades 1,337.00 Permanent YES
1/1/1986 6/30/1986 Teacher Cabarroguis National School of Arts & Trades 1,096.00 Permanent YES
1/1/1985 12/31/1985 Teacher Cabarroguis National School of Arts & Trades 1,053.00 Permanent YES
7/2/1984 12/31/1984 Teacher Cabarroguis National School of Arts & Trades 957.00 Permanent YES
 (Continue separate sheet if necessary)
CS FORM 212 (Revised 2005), Pae 2 of 4

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

31. NATURE AND ADDRESS OF ORGANIZATION INCLUSIVE DATES (mm/dd/yyyy) NUMBER CONDUCTED/SPONSORED BY
(Write in Full) From To OF HOURS (Write in Full)
Purok & Barangay Adviser 11/28/1987 Present 2 hrs/m adviser
Gundaway, Cabarrouis, Quirino

Jesus Christ Saves Global Outreach 05/29/1991 Present 4 hrs/wk Ministerial Leader
Ministerial Work, Nagtipunan, Quirino

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

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

The School Heads CEO & Technology Leader 12/1/2003 12/6/2003 48 SEAMEO INNOTECH
Rubrics & Potfolio Assessment of Authentic
Learnings for School Based INSET Trainors 05/03/2004 05/04/2004 24 DepEd & Phil. Normal University
Orientation Seminar Workshop for Promulgated
Building Program 3/3/2004 3/6/2004 40 DepEd Central Office
Redefining Supervision 01/12/2004 01/16/2004 40 DepEd Quirino
Conference and Direct Fund Release 09/07/2004 09/07/2004 8 DepEd Regional Office
Division Training of Treasurer Facilitator of the BP 06/09/2004 06/11/2004 24 DepEd Quirino
Teacher Training on INTEL TEACH to the Future 10/25/2004 12/1/2004 80 DepEd - CNSAT
Division Training on Assessment of Learning Outcomes 01/22/2004 07/23/2004 16 DepEd Quirino

VIII. OTHER INFORMATION

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

Video Camera Operation - Recognition & Testimonial as chairman
Wood & Electrical Works committee on parade for Quirino Day & CAVRAA
Driving - Recognition as Chairman Committee on Stage
Computer Literate Decoration Municipal and Provincial
- Recognition as Chairman on Booth Decoration
for winning as champion (Cabarroguis Booth 2007)
- Adviser CNSAT Teachers, employees, &
Retirees Association.
- Adviser CNSAT-MULTI Purpose Coop.
- Adviser Quirino Publication Teachers,
employees, & Retirees Association
- Vice President Quirino Public Secondary
School Administrators Association.
- Head-Technical Working Group of Accreditation
and Trade Testing (TESDA)
 CS FORM 212 (Revised 2005), Pae 3 of 4
36. Are you realated by consanguinity or afinity of the following
a. within the third degree (for Nationa Government Employees): YES / NO
Appointing authority, recommending authority, chief of office/bureau/department or person who has if YES, give details:
immediate supervision over you in the Office, Bureau of Department were 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 regulation by any
court or tribunal YES / NO
if YES, give details:

39. Have you ever been separated from the serice 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 YES / NO
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 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: YES / NO
if YES, give details:
a. Are you a member of any indingenous group?

b. Are you differently abled? YES / NO

if YES, give details:

c. Are you solo parent? YES / NO

if YES, give details:

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

NAME ADDRESS TEL. NO.
Rev. Pastor Ronald Bonus Jr. San Andress, Santiago City 0917-574-1511
Dr. William P. Binwag Zamora, Cabarroguis, Quirino
Dr. David Richard O. Longid Cabarroguis, Quirino 0926-680-8717

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 law, 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.
 24640358
COMMUNITY TAX CERTIFICATE NO.
Gundaway, Cabarroguis, Quirino
ISSUED AT SIGNATURE (Sign inside the box)

January 07, 2009

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Pae 4 of 4
m/dd/yyy)
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ed 2005), Pae 1 of 4

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GOVT
SERVICE
(Yes/No)

YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
ed 2005), Pae 2 of 4

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ed 2005), Pae 3 of 4
ed 2005), Pae 4 of 4