CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

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 FIRST NAME MIDDLE NAME 4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX

B O D E A R N O L D F E L I X 4/27/1983 Lanuza, Surigao del Sur

Male Single Married Annulled 3. NAME EXTENSION (e.g. Jr., Sr.

7. CIVIL STATUS

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11.BLOOD TYPE 12. GSIS NO. 13. PAG-IBIG NO. 14. PHILHEALTH NO. 15. SSS NO.

FILIPINO
5'3 51kg A+

16. RESIDENTIAL ADDRESS

ZoneI, Lanuza, Surigao del Sur 8 3 1 4

Female

Widowed Separated Others,specify_______

ZIP CODE 17. TELEPHONE NO.

18. PERMANENT ADDRESS

ZoneI, Lanuza, Surigao del Sur 8 3 1 4

arnefex@yahoo.com

ZIP CODE 19. TELEPHONE NO.

20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO.

2 0 0 3 4 4 2 8 3 4 1 8 3 0 0 0 6 4 0 5 7 2 1 8 0 0 0 0 4 7 0 1 3 7

23. TIN

946-790-779
DATE OF BIRTH (mm/dd/yyyy)

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO.
(Continue on separate sheet if neessay)

CUBERO DELIA CABANLIT TEACHER

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

26. FATHER'S SURNAME FIRST NAME MIDDLE NAME

27. MOTHER'S MAIDEN NAME

BODE CARLOS VICTORIANO

SURNAME FIRST NAME MIDDLE NAME III. EDUCATIONAL BACKGROUND

28. LEVEL

FELIX MERILYN RAMIREZ

HIGHEST YEAR GRADE/LEVEL GRADUATED UNITS EARNED (if graduated) (if not graduated) INCLUSIVE DATES OF ATTENDANCE From To

NAME OF SCHOOL (Write in full)

DEGREE COURSE (Write in full)

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

ELEMENTARY SECONDARY VOCATIONAL/ TRADE COURSE COLLEGE GRADUATE STUDIES

TALIPAPA ES (CALOOCAN CITY) SSIT-LANUZA BRANCH

1996 2000

GRADUATED GRADUATED

1990 1996

1996 2000

1st Honors Salutatorian

SSPSC-MAIN TANDAG BSU-GES Surigao City

2005

GRADUATED
9 UNITS

2000

2005

(Continue on separate sheet if neessay)

Page 1of 4

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/R.A. 1080 (BOARD/BAR) UNDER SPECIAL LAWS/CES/CSEE RATING DATE OF EXAMINATION/ CONFERMENT PLACE OF EXAMINATION/CONFERMENT

LICENSE (if applicable)

NUMBER DATE OF RELEASE

Licensure Examination for Teachers

81

14-Aug-05

Cagayan de Oro City

903169

12/28/2005

Continue on separate sheet if necessary

V. WORK EXPERIENCE (Include private employment. Start from your current work.)
30. INCLUSIVE DATE (mm/dd/yyyy) From
Dec. 10, 2009 Sept. 10, 2007 / / / / / / / / / / / / / / / / / / / / / / / / / / / /

To
Present Dec. 9, 2009 / / / / / / / / / / / / / / / / / / / / / / / / / / / /

POSITION TITLE (Write in full)

T-1 T-1

DEPARTMENT/AGENCY/ OFFICE/COMPANY (Write in full) LCES NIS

MONTHLY SALARY

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

STATUS OF APPOINTMENT

GOV'T SERVICE (Yes/No)

/ / / / / / / / / / / /

/ / / / / / / / / / / /

/ / / / / / / / / / / /

/ / / / / / / / / / / /

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 AND ADDRESS OF ORGANIZATION (Write in full)
INCLUSIVE DATE (mm/dd/yyyy)

From

To

NUMBER OF HOURS

POSITION/NATURE OF WORK

Continue on separate sheet if necessary

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

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) Induction/INSET Program Induction/INSET Program Division Training Workshop on Test Construction in five learning areas (Elem. Level) 2-Day Re-Echo Training Workshop for Makabayan Teachers 2009 Orientation of the National Carreer Assesment Exam.
INCLUSIVE DATE OF ATTENDANCE (mm/dd/yyyy)

From 10/22/2007 5/5/2008 7/2/2008 9/5/2008 8/17/2009

To 10/26/2007 5/9/2008 7/3/2008 9/6/08 8/17/2009 10/14-16/2009 9/30/2009 7/3&10/2010 7/9&10/2011 8/9/2011

NUMBER OF HOURS 40 40 16 16 8 40 40 24 24 8

CONDUCTED/SPONSORED BY (Write in full.)

Dep.Ed. Dep.Ed. Dep.Ed. Dep.Ed. Dep.Ed. CICT LISURKA & Dep.Ed. Dep.Ed. Dep.Ed. Dep.Ed.

Computer and Internet Literacy Course (CILC) 9/20-22/2009 Teachers Training on effective Teaching Strategies on the use of ICT 9/26/2009 3-Day School Based ICT Training 3 -Day Orientation of Advocacy and Communication on SBM 6/26/2010 7/2/2011

Division Leadership Training and Election of SPG Officers & Advisers 8/9/2011

3-Day Division Training Workshop on Web-Enhanced Learning Activities (WELA) & Computer Aided Instructional Materials

9/23/2011

9/25/2011

24

Dep.Ed.

Continue on separate sheet if necessary

VIII. OTHER INFORMATION

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

Continue on separate sheet if necessary 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. With 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?

YES

NO

If YES, give details:

b. Have you ever been guilty of any admnistrative 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 service in any of the following modes: resignation, retirement

YES

NO

dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector? 40. Have you ever been a candidate in a noational or local election (except Barangay election)?

If YES, give details:

YES

NO

If YES, give details:

41. Pursuant to: (a) Indigenous People's Act (RA 8371): (b) Magna Carta for Disabled Person (RA 7277); and ( c) Solo Parent Welfare Act of 2000 (RA 8972),please answer the following items: a. Are you a member of 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 consaguinity or affinity to applicant/appointee) NAME

TERESITA F. FUERTE SOL U. BUNIEL BENNY T. ABALA

ADDRESS
Lanuza, Surigao del Sur Madrid, Surigao del Sur Tandag, Surigao del Sur

TEL. NO.
ID picture taken within the last 6 months 3.5 cm. x 4.5 cm. (passport size)

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 content stated herein. I trust that this information shall remain confidential.

Computer generated or xerox copy of picture is not acceptable.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK
CS FORM 212 (Revised 2005). Page 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.

(to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME 4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 3. NAME EXTENSION (e.g. Jr., Sr.

7. CIVIL STATUS

Male Single Married Annulled

16. RESIDENTIAL ADDRESS

Female

Widowed Separated Others,specify_______

ZIP CODE 17. TELEPHONE NO.

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11.BLOOD TYPE 12. GSIS NO. 13. PAG-IBIG NO. 14. PHILHEALTH NO. 15. SSS NO.

18. PERMANENT ADDRESS

ZIP CODE 19. TELEPHONE NO.

20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO.

23. TIN

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO.
(Continue on separate sheet if neessay)

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

DATE OF BIRTH (mm/dd/yyyy)

26. FATHER'S SURNAME FIRST NAME MIDDLE NAME

27. MOTHER'S MAIDEN NAME

SURNAME FIRST NAME MIDDLE NAME III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SECONDARY VOCATIONAL/ TRADE COURSE COLLEGE GRADUATE STUDIES

(Continue on separate sheet if neessay)

Page 1of 4

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/R.A. 1080 (BOARD/BAR) UNDER SPECIAL LAWS/CES/CSEE RATING DATE OF EXAMINATION/ CONFERMENT PLACE OF EXAMINATION/CONFERMENT

LICENSE (if applicable)

NUMBER DATE OF RELEASE

Continue on separate sheet if necessary

V. WORK EXPERIENCE (Include private employment. Start from your current work.)
30. INCLUSIVE DATE (mm/dd/yyyy) From
/ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

To
/ / / / / / / / / / / / / / /

POSITION TITLE (Write in full)

DEPARTMENT/AGENCY/ OFFICE/COMPANY (Write in full)

MONTHLY SALARY

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

STATUS OF APPOINTMENT

GOV'T SERVICE (Yes/No)

/ / / / / / / / / / / / /

/ / / / / / / / / / / / /

/ / / / / / / / / / / / /

/ / / / / / / / / / / / /

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 AND ADDRESS OF ORGANIZATION (Write in full)
INCLUSIVE DATE (mm/dd/yyyy)

From

To

NUMBER OF HOURS

POSITION/NATURE OF WORK

Continue on separate sheet if necessary

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

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)
INCLUSIVE DATE OF ATTENDANCE (mm/dd/yyyy)

From

To

NUMBER OF HOURS

CONDUCTED/SPONSORED BY (Write in full.)

Continue on separate sheet if necessary

VIII. OTHER INFORMATION

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

Continue on separate sheet if necessary

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. With 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?

YES

NO

If YES, give details:

b. Have you ever been guilty of any admnistrative 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

YES

NO

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, retirement dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector? 40. Have you ever been a candidate in a noational or local election (except Barangay election)?

YES If YES, give details:

NO

YES

NO

If YES, give details:

41. Pursuant to: (a) Indigenous People's Act (RA 8371): (b) Magna Carta for Disabled Person (RA 7277); and ( c) Solo Parent Welfare Act of 2000 (RA 8972),please answer the following items: a. Are you a member of 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 consaguinity or affinity to applicant/appointee) NAME ADDRESS TEL. NO.
ID picture taken within the last 6 months 3.5 cm. x 4.5 cm. (passport size)

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 content stated herein. I trust that this information shall remain confidential.

Computer generated or xerox copy of picture is not acceptable.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK
CS FORM 212 (Revised 2005). Page 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.

(to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME 4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 3. NAME EXTENSION (e.g. Jr., Sr.

7. CIVIL STATUS

Male Single Married Annulled

16. RESIDENTIAL ADDRESS

Female

Widowed Separated Others,specify_______

ZIP CODE 17. TELEPHONE NO.

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11.BLOOD TYPE 12. GSIS NO. 13. PAG-IBIG NO. 14. PHILHEALTH NO. 15. SSS NO.

18. PERMANENT ADDRESS

ZIP CODE 19. TELEPHONE NO.

20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO.

23. TIN

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO.
(Continue on separate sheet if neessay)

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

DATE OF BIRTH (mm/dd/yyyy)

26. FATHER'S SURNAME FIRST NAME MIDDLE NAME

27. MOTHER'S MAIDEN NAME

SURNAME FIRST NAME MIDDLE NAME III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SECONDARY VOCATIONAL/ TRADE COURSE COLLEGE GRADUATE STUDIES

(Continue on separate sheet if neessay)

Page 1of 4

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/R.A. 1080 (BOARD/BAR) UNDER SPECIAL LAWS/CES/CSEE RATING DATE OF EXAMINATION/ CONFERMENT PLACE OF EXAMINATION/CONFERMENT

LICENSE (if applicable)

NUMBER DATE OF RELEASE

Continue on separate sheet if necessary

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

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 AND ADDRESS OF ORGANIZATION (Write in full)
INCLUSIVE DATE (mm/dd/yyyy)

From

To

NUMBER OF HOURS

POSITION/NATURE OF WORK

Continue on separate sheet if necessary

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

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)
INCLUSIVE DATE OF ATTENDANCE (mm/dd/yyyy)

From

To

NUMBER OF HOURS

CONDUCTED/SPONSORED BY (Write in full.)

Continue on separate sheet if necessary

VIII. OTHER INFORMATION

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

Continue on separate sheet if necessary 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. With 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?

YES

NO

If YES, give details:

b. Have you ever been guilty of any admnistrative 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 service in any of the following modes: resignation, retirement

YES

NO

dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector? 40. Have you ever been a candidate in a noational or local election (except Barangay election)?

If YES, give details:

YES

NO

If YES, give details:

41. Pursuant to: (a) Indigenous People's Act (RA 8371): (b) Magna Carta for Disabled Person (RA 7277); and ( c) Solo Parent Welfare Act of 2000 (RA 8972),please answer the following items: a. Are you a member of 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 consaguinity or affinity to applicant/appointee) NAME ADDRESS TEL. NO.
ID picture taken within the last 6 months 3.5 cm. x 4.5 cm. (passport size)

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 content stated herein. I trust that this information shall remain confidential.

Computer generated or xerox copy of picture is not acceptable.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK
CS FORM 212 (Revised 2005). Page 4 of 4