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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 A| Q | U | I | N | O | | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME L | U | N | E | T | A | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME B | O | A | C | | | | | | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.)


16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy) 10/06/1972
5. PLACE OF BIRTH #11 PONCE, ST. DISTRICT IV, BAYOMBONG, NUEVA VIZCAYA
6. SEX Male Female
7. CIVIL STATUS
Single Widowed ZIP CODE 3700
Married Separated 17. TELEPHONE NO. N/A
Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP FILIPINO #11 PONCE, ST. DISTRICT IV, BAYOMBONG, NUEVA VIZCAYA
9. HEIGHT (m) 1.58Annulled
10. WEIGHT (kg) 42 KGS ZIP CODE 3700
11. BLOOD TYPE O 19. TELEPHONE NO. N/A
12. GSIS ID NO. 2427745 20. E-MAIL ADDRESS (if any) N/A
13. PAG-IBIG ID NO. 20117557109 21. CELLPHONE NO. (if any) 09368053744
14. PHILHEALTH NO. 19-000670848-3 22. AGENCY EMPLOYEE NO. 4210160
15. SSS NO. None 23. TIN 175-592-183
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME AQUINO 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAMEFLORENTINO JR. RUSSEN B AQUINO 10/29/ 1996


MIDDLE NA BUENO HANES DIANNE B. AQUINO 06/06/2000
OCCUPATION SELF-EMPLOYED VANN HESLEY B. AQUINO 02/08/2000
EMPLOYER/BUS. NAME PRIVATE / /
BUSINESS ADDRESS DISTRICT IV, BAYOMBONG, NUEVA VIZCAYA / /
TELEPHONE NO. N/A / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME BOAC / /
FIRST NAME TOLEDO / /
MIDDLE NAME CANERO / /
27. MOTHER'S MAIDEN NAME / /
SURNAME BOAC / /
FIRST NAME LILY (DECEASED) / /
MIDDLE NAME QUIAOIT (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR


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

(if graduated) 2ND HONORABLE


ELEMENTARY CAREB ELEMENTARY SCHOOL ELEMENTARY 1985 N/A 1979 1985
MENTION
2ND HONORABLE
SECONDARY NUEVA VIZCAYA POLYTECHNIC COLLEGE SECONDARY 1989 N/A 1985 1989
VOCATIONAL / MENTION

N/A N/A N/A NONE N/A N/A N/A


COLLEGE
TRADE COURSE BACHELOR OF
NUEVA VIZCAYA 1993 N/A 1989 1993 N/A
SCIENCE
IN ELEMENTARY
STATE UNIVERSITY
EDUCATION
GRADUATE STUDIES
NUEVA VIZCAYA MASTER N/A 33 1994 1996 N/A

STATE UNIVERSITY OF EDUCATION

(Continue on separate sheet if necessary)


Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE
PROFESSIONAL BOARD EXAMINATION FOR MAY 29,
73.96% 11/13/1994 BAYOMBONG, NUEVA VIZCAYA 0401066
TEACHERS 1994

(Continue on separate sheet if necessary)


V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY
(mm/dd/yyyy) MONTHLY GRADE & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
01/01/2017 DATE TEACHER III DEPARTMENT OF EDUCATION 23,786 13-7 PERMANENT YES

07/31/2016 12/31/2016 TEACHER III DEPARTMENT OF EDUCATION 23,786 13-7 PERMANENT YES

01/01/2016 07/30/2016 TEACHER III DEPARTMENT OF EDUCATION 23,536 13-6 PERMANENT YES

07/31/2013 12/31/2015 TEACHER III DEPARTMENT OF EDUCATION 22,529 13-6 PERMANENT YES

03/01/2012 07/30/2013 TEACHER III DEPARTMENT OF EDUCATION 22,306 13-6 PERMANENT YES

06/01/2011 05/31/2012 TEACHER III DEPARTMENT OF EDUCATION 20,682 13-6 PERMANENT YES

07/31/2010 05/31/2011 TEACHER III DEPARTMENT OF EDUCATION 19,058 13-5 PERMANENT YES

06/24/2010 07/30/2010 TEACHER III DEPARTMENT OF EDUCATION 18,755 13-5 PERMANENT YES

07/01/2009 06/25/2010 TEACHER III DEPARTMENT OF EDUCATION 17,089 13-5 PERMANENT YES

07/01/2008 06/30/2009 TEACHER III DEPARTMENT OF EDUCATION 14,552 13-5 PERMANENT YES

07/31/2007 06/30/2008 TEACHER III DEPARTMENT OF EDUCATION 13,229 13-5 PERMANENT YES

07/01/2007 07/30/2007 TEACHER III DEPARTMENT OF EDUCATION 12,906 13-4 PERMANENT YES

07/31/2004 06/30/2007 TEACHER III DEPARTMENT OF EDUCATION 11,733 13-4 PERMANENT YES

07/31/2001 07/30/2004 TEACHER III DEPARTMENT OF EDUCATION 11,446 13-3 PERMANENT YES

07/01/2001 07/08/2001 TEACHER III DEPARTMENT OF EDUCATION 11,167 13-2 PERMANENT YES

01/01/2000 06/30/2001 TEACHER III DEPARTMENT OF EDUCATION 10,635 13-2 PERMANENT YES

07/31/1998 12/31/1999 TEACHER III DEPARTMENT OF EDUCATION 9,668 13-2 PERMANENT YES

11/01/1997 07/30/1998 TEACHER III DEPARTMENT OF EDUCATION 8,605 11-1 PERMANENT YES

01/01/1997 10/31/1997 TEACHER III DEPARTMENT OF EDUCATION 7,309 11-1 PERMANENT YES

01/01/1996 12/31/1996 TEACHER III DEPARTMENT OF EDUCATION 6,013 11-1 PERMANENT YES

08/24/1995 12/31/1995 TEACHER III DEPARTMENT OF EDUCATION 4,902 11-1 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
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

N/A N/A N/A N/A N/A

/ / / /

/ / / /

/ / / /

/ / / /
(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 NUMBER OF CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) HOURS (Write in full)
From To
EARLY LANGUAGE, LITERACY AND NUMERACY PROGRAM
11/ /2016 03/ /2017 DEPARTMENT OF EDUCATION
FOR K-3 TEACHERS
DISTRICT SEMINAR WORKSHOP ON SIM, BIG BOOK, ICT
06/06/2016 06/08/2016 16 DEPARTMENT OF EDUCATION
BASED MODULE AND IM'S PREPARATION
DIVISION K-TO-12 CURRICULUM MASS TRAINING FOR
05/12/2014 05/17/2014 48 DEPARTMENT OF EDUCATION
GRADE-III TEACHERS
GRADE READING ASSESSMENT (EGRA) AND RESULTS
05/16/2013 05/17/2013 16 DEPED BAYOMBONG
ASSOCIATED TEACHING ACTIVITIES (ARATA)
SEMINAR WORKSHOP ON INCLUSION OF LEARNERS WITH
04/03/2013 04/05/2013 24 SAINT LOUIS UNIVERSITY
VISUAL IMPAIRMENT IN REGULAR SCHOOLS

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(Write in full)
SINGING, DANCING NONE NONE

(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 :

a. Within the third degree (for National Government Employees): YES NO


appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
has immediate supervision over you in the Office, Bureau or Department where 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 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.

EDWARD M. SANTIAGO BAYOMBONG, NUEVA VIZCAYA N/A ID picture taken within


the last 6 months
LINDA RAROS BAYOMBONG, NUEVA VIZCAYA N/A 3.5 cm. X 4.5 cm
(passport size)
EDYMEL D. CALACALA BAYOMBONG, NUEVA VIZCAYA N/A
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines.

I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential. PHOTO

06768187
COMMUNITY TAX CERTIFICATE NO. LUNETA B. AQUINO
DISTRICT IV, BAYOMBONG, NUEVA VIZCAYA
ISSUED AT SIGNATURE (Sign inside the box)

01/13/2017 04/07/2017
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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