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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
L

| A | S | T | I | E | R | E |

FIRST NAME

| O | V | E | N |

MIDDLE NAME

A | P

2. SURNAME

| I | S | T | A | R |
11/23/1991

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

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6. SEX
7. CIVIL STATUS

Female

Single
Married

Widowed
Separated

8. CITIZENSHIP

Filipino

9. HEIGHT (m)

1.575 m.

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

16. RESIDENTIAL ADDRESS

Rica Villagae Tabuc Suba Jaro, Iloilo City

Male

Annulled

ILOILO CITY

5. PLACE OF BIRTH

ZIP CODE

5000
+639053730083

17. TELEPHONE NO.


18. PERMANENT ADDRESS

Others, specify
___________

Rica Villagae Tabuc Suba Jaro, Iloilo City

10. WEIGHT (kg)

45 kg.

11. BLOOD TYPE

19. TELEPHONE NO.

09496111845

12. GSIS ID NO.

N/A

20. E-MAIL ADDRESS (if any)

joven_lastiere@wvsu.edu.ph

13. PAG-IBIG ID NO.

N/A

21. CELLPHONE NO. (if any)

+639053730083

14. PHILHEALTH NO.

11-050558685

22. AGENCY EMPLOYEE NO.

N/A

15. SSS NO.

07-2729635

23. TIN

420270135

ZIP CODE

5000

II. FAMILY BACKGROUND


N/A

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

FIRST NAME

N/A

N/A

MIDDLE NAME

N/A

24. SPOUSE'S SURNAME

OCCUPATION

N/A

EMPLOYER/BUS. NAME

N/A

BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

DATE OF BIRTH (mm/dd/yyyy)

8/17/1966

LASTIERE

26. FATHER'S SURNAME


FIRST NAME

DOMINGGO

MIDDLE NAME

EPACTA

27. MOTHER'S MAIDEN NAME


SURNAME

APISTAR

FIRST NAME

CELIA

MIDDLE NAME

PALIZADA

12/29/1957

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

DEGREE COURSE
(Write in full)

full)

ELEMENTARY

Maacabac Elementary School

Elementary

SECONDARY
VOCATIONAL /

Iloilo National High School

West Visayas State University

(if
graduated)

HIGHEST GRADE/
LEVEL/UNITS EARNED
(if not
graduated)

INCLUSIVE DATES OF
ATTENDANCE
From

To

2004

Graduated

1998

2004

Secondary

2008

Graduated

2004

2008

BSED-ENGLISH

2012

Graduated

2008

2012

SCHOLARSHIP/ ACADEMIC
HONORS RECEIVED

TRADE
COURSE
COLLEGE

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

PROFESSIONAL BOARD EXAMINATIONS FOR


TEACHERS

LICENSE (if applicable)

RATING

DATE OF EXAMINATION /
CONFERMENT

PLACE OF EXAMINATION /
CONFERMENT

NUMBER

DATE OF
RELEASE

76.00%

Sept. 30,2012

ILOILO CITY

1187204

4/16/2013

(Continue on separate sheet if necessary)

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

INCLUSIVE
DATES
(mm/dd/yyyy)

POSITION TITLE
(Write in full)

DEPARTMENT / AGENCY / OFFICE /


COMPANY
(Write in full)

From

To

04/08/2013

03/31/14

Faculty Member-Elementary Department

Iloilo Schlastic Academy

7/27/2015

PRESENT

Faculty- TCT-AR FIS

Departnment of Education

GOV'T
SERVICE
MONTHLY
SALARY

11,000

SALARY GRADE &


STEP INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT

(Yes / No)
Probationary

NO

PERMANENT

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)

NUMBER OF
HOURS

(mm/dd/yyyy)

Our Lady of Miraculous Medal- West visayas State University


Medical Center

From

To

10 / 26/ 2013

Present

POSITION / NATURE OF WORK

Lector/ Commentator

(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)

(mm/dd/yyyy)

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

From

To

Annual Students' Congress

2/10/2012

2/12/2012

72

Philippine Association for Teacher


Education

49th National Rizal Youth Leadership Institue Conference

12/10/2011

12/14/2011

120

Order of the Knights of Rizal

West Visayas State University College of Education's Strategic


Planning Workshop (2011-2015)

12/7/2013

12/7/2013

West Visayas State UniversityCollege of Education

CARPENTRY NCII

9/1/2015

10/2/2015

DIVISION INSET FOR ENGLISH TEACHERS

10/26/2015

10/28/2015

32

Department of Education - Division of Iloilo City

SCHOOL INSET

10/29/2015

10/30/2015

16

Department of Education- Tiu Cho Teg- Ana Ros


Foundation Integrated School

TESDA

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


tration

SPECIAL SKILLS / HOBBIES:

34.

NON-ACADEMIC DISTINCTIONS / RECOGNITION:


(Write in full)

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)

Fashion

Education Student Council - Business Manager 2010-2011

Photography

Education Student Council - Vice- Chaiperson 2011-2012

N/A

Graphic Designs
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4

36.

Are you related by consanguinity or affinity to any of the following :


YES

a.

b.

37

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?

NO

If YES, give details:


_________________________________
_________________________________
_________________________________
YES

Within the fourth degree (for Local Government Employees):


appointing authority or recommending authority where you will be appointed?

NO

If YES, give details:


________________________________
________________________________

a. Have you ever been formally charged?

YES
NO
If YES, give details:
________________________________
________________________________
YES

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

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?

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.

YES
NO
If YES, give details:
________________________________
________________________________
YES

NO

If YES, give details: _Yes, through resignation in


a private school.___________________
__________________________________

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:
YES

a.

Are you a member of any indigenous group?

b.

Are you differently abled?

c.

Are you a solo parent?

NO

If YES, please specify: ____________________


If YES, please specify: ____________________
If YES, please specify: ____________________
42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
NAME

Mr. Peter Chan

TEL. NO.

Molo, Iloilo Ciy

Mr. Raymond Peter T. Tolentino


Ms. Kriel Rose Franco
43.

ADDRESS

6391890180

Tiu Cho Teg- Ana Ros Foundation Integrated School


Tiu Cho Teg- Ana Ros Foundation Integrated School

3960061
9106242597

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

27639174
COMMUNITY TAX CERTIFICATE NO.

ILOILO CITY
ISSUED AT

SIGNATURE (Sign inside the box)

1/20/2015

11/2/2015

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK

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