CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15250876

1. CS ID
Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME MACAYA
FIRST NAME KAYE
MIDDLE NAME RANER 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS Brgy. Delicioso, ILOG, NEGROS OCCIDENTAL

4. DATE OF BIRTH (mm/dd/yyyy) 12 / 13 / 1994
5. PLACE OF BIRTH Kabankalan City
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 6109
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Brgy. Delicioso, ILOG, NEGROS OCCIDENTAL

8. CITIZENDSHIP Filipino
9. HEIGHT (m) 1.63
10. WEIGHT (kg) 50 ZIP CODE 6109
11. BLOOD TYPE O+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) eyak135@gmail.com

13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any) 09384100133
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 07-3747056-3 23. TIN

II. FAMILY BACKGROUND

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

FIRST NAME 01 / 01 / 1970

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Macaya

FIRST NAME Ramon Sr.

MIDDLE NAME Gargaran

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Raner

FIRST NAME Elizabeth

MIDDLE NAME Tabat

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Delicioso Elementary School 2007 4th Honorable mention

Immaculate Conception
SECONDARY 2011
Academy

VOCATIONAL/ TRADE
COURSE

Bachelor of 2016-03-
COLLEGE Kabankalan Catholic College 2016 2012
Elementary Education 29

GRADUATE STUDIES

IV. CIVIL SERVICE ELIGIBILITY

MACAYA, KAYE RANER - T15250876 CS FORM 212 (Revised 2005), Page 1 of 3
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 76.20 03 / 26 / 2017 Bacolod City 1548785 06/21/2017

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")

Immaculate Conception
06/13/2018 01/25/2019 Teaching Assisstant Academy Inc. Pre-School 0-0 No
Department

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

JCI CHICKS United 2015 Present

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

Grande Computer Outreach and

Basic Computer Course 12 / 09 / 2017 01 / 14 / 2018 80
Training Center Inc.

Training for Work Scholarship

National Certififate II in Cookery 11 / 23 / 2017 04 / 18 / 2018
Program

Seminar-Workshop on Data Analysis for Education 109 09 / 25 / 2014 09 / 28 / 2014 Feliciano O. Peduhan Ph.D

VIII. OTHER INFORMATION

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

JCI CHICKS United

MACAYA, KAYE RANER - T15250876 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.

Jennifer M. Melliza Block 6 Lot 8 Grandville II Subd. Brgy. 09081634258

Mansilingan Bacolod City
Danilo P. Tabat Brgy. Dancalan, Ilog, Neg. Occ. 09999331586

Gloria D. Gena Brgy. Delicioso, Ilog, Neg. Occ 09189190465

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

21091002

COMMUNITY TAX CERTIFICATE NO.

Delicioso, Ilog, Neg. Occ

ISSUED AT SIGNATURE (Sign inside the box)

2018-03-08 03 / 10 / 2018

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

MACAYA, KAYE RANER - T15250876 CS FORM 212 (Revised 2005), Page 3 of 3