pdsrev2005.xls

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 A | L | M | A | | | | | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME C | A | F |E | | | | | | | | | | | | | | | | |3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 12/12/1968 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH Mati City

6. SEX

7. CIVIL STATUS ZIP CODE 8207

17. TELEPHONE NO.

18. PERMANENT ADDRESS

8. CITIZENSHIP Filipino

9. HEIGHT (m) 5' 4"

10. WEIGHT (kg) 64 kgs. ZIP CODE

11. BLOOD TYPE O 19. TELEPHONE NO. N/A

GSIS ID NO. 68121201783 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 1210-4619-8228 21. CELLPHONE NO. (if any) 0908-5630518

14. PHILHEALTH NO. 19-000753984-7 22. AGENCY EMPLOYEE NO.

15. SSS NO. N/A 23. TIN 133-613-918

II. FAMILY BACKGROUND

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

FIRST NAME JESSILITO Not Applicable / /

MIDDLE NAME FAJARDO / /

OCCUPATION SENIOR FIRE OFFICER I / /

EMPLOYER/BUS. NAME BUREAU OF FIRE PROTECTION / /

BUSINESS ADDRESS LUPON, DAVAO ORIENTAL / /

TELEPHONE NO. / /

(Continue on separate sheet if necessary) / /

26. FATHER'S SURNAME CAFÉ SR. (DECEASED) 10/03/1933

FIRST NAME CUSTODIO / /

MIDDLE NAME DAGUPLO / /

27. MOTHER'S MAIDEN NAME / /

SURNAME TOMAS (DECEASED) 04/29/1936

FIRST NAME MILAGROS / /

MIDDLE NAME ALLADO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.LEVEL

From To

ELEMENTARY Lupon Central Elementary School - 1 1981 1975 1981 Class Valedictorian

SECONDARY Maryknoll High School of Lupon 1985 1982 1985 With Honors

COLLEGEMapua Institute of Technology BS Mining Eng'g. 1985

Ateneo de Davao University BSE - Mathematics 1990 1985 1990

GRADUATE STUDIES Univeristy of Southeastern Philippines MA Math 6 units 1993 1994

University of San Carlos MAST - Math 33 units 1994 1998

(Continue on separate sheet if necessary)

Page 1 of 4

A | N | D | O | | | | | | | | | | | | | | | | | | | | | | | | | | | |

Lot 3, Block 2, Phase III, Purok Paglaum, Poblacion, Lupon, Davao Oriental

12. [email protected]

NAME OF SCHOOL (Write in

full)

DEGREE COURSE (Write in full)

YEAR GRADUATED (if graduated)

HIGHEST GRADE/ LEVEL/

UNITS EARNED (if not graduated)

INCLUSIVE DATES OF ATTENDANCE SCHOLARSHIP/

ACADEMIC HONORS RECEIVED

VOCATIONAL / TRADE COURSE

Male Female

Annulled Others, specify ___________

Single

Married

Widowed

Separated

mailto:[email protected]

IV. CIVIL SERVICE ELIGIBILITY

29.RATING PLACE OF EXAMINATION / CONFERMENT

LICENSE (if applicable)

NUMBER

CS Subprof 72.38% 07/26/1987 Davao City 1/13/88

CS Prof 82.16% Aug. 15, 1999 Davao City 8/23/99

PBET 70.73% Nov. 25, 1990 Davao City 1274056 7/12/91


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

30.

From To

01/01/2014 12/31/2014 Teacher II Lupon Vocational High School Perm Yes

11/25/2013 12/31/2013 Teacher II Lupon Vocational High School Perm Yes

01/01/2013 11/24/13 Teacher I Lupon Vocational High School Perm Yes

06/01/12 12/31/12 Teacher I Lupon Vocational High School EO 76 Perm Yes


07/08/11 12/31/11 Teacher I Lupon Vocational High School Step 4 Perm Yes

06/01/11 7/7/11 Teacher I Lupon Vocational High School NBC 530 Perm Yes












07/08/05 12/31/05 Teacher I Lupon Vocational High School Step 2 Perm Yes



01/01/03 12/31/03 Secondary School Teacher I Lupon Vocational High School Perm Yes

07/08/02 12/31/02 Secondary School Teacher I Lupon Vocational High School NBC 474 Perm

01/01/90 05/11/01 Teacher The Phil. Women's College of Davao Perm Yes


CS FORM 212 (Revised 2005), Page 2 of 4

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE

DATE OF EXAMINATION / CONFERMENT DATE OF

RELEASE

INCLUSIVE DATES (mm/dd/yyyy) 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)

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

31.POSITION / NATURE OF WORK

From To

None / / / /

/ / / /

/ / / /

/ / / /

/ / / /


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

32.

From To

10/27/2014 10/28/2014 16 DepED

Basic Computer Operations and Concepts Training 09/06/2014 09/13/2014 16 DepED

02/21/2014 02/23/2014 24 DepED/SBM

09/25/2013 09/27/2013 24 DepEd

Microsoft Basic Operation Training 04/18/2013 04/20/2013 24 DepEd

12/05/2011 12/09/2011 40

11/21/2011 11/25/2011 40

08/08/2011 08/13/2011 48

07/25/2011 07/30/2011 48

Trainers and Assessors Methodology 1 course 05/16/2011 05/27/2011 96 TESDA


VIII. OTHER INFORMATION

33. SPECIAL SKILLS / HOBBIES: 34. 35.

Webpage Designer

Visual Graphics Designer



NAME & ADDRESS OF ORGANIZATION (Write in full)

INCLUSIVE DATES

(mm/dd/yyyy) NUMBER OF HOURS

TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)

INCLUSIVE DATES OF ATTENDANCE

(mm/dd/yyyy) NUMBER OF HOURS

CONDUCTED/ SPONSORED BY (Write in full)

Enhancement Training of Teaching-Learning Capabilities through ICT Integration for Teachers

School Based ICT Training on Using Video as a Teaching and Learning Tool

Regional Video Production, Editing and Authoring Training-workshop

Workshop on the Finalization/Packaging of the Competency-Based Learning Materials (CBLM) in Different Areas of Specialization (Workshop 2)

DepEd Techvoc Education Task Force

Workshop on the Integration of Evaluation Results/Recommendations by the Instructional Materials Council Secretariat (IMCS) Editors/Evaluators (Workshop 1)


Workshop to Redesign/Enrich the ICT Learning Materials against the Calibrated Competency-Based Curriculum (CBC)


Workshop to Calibrate/Match/Develop the Competencies for ICT Competency-Based Curriculum (CBC) based on the TESDA Training Regulations


NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

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

a.

b.

37 a. Have you ever been formally charged?

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

38.

39.

40. Have you ever been a candidate in a national or local election (except Barangay election)?

41.

a. Are you a member of any indigenous group?If YES, please specify: ____________________

b. Are you differently abled?If YES, please specify: ____________________

c. Are you a solo parent?If YES, please specify: ____________________

42.

NAME ADDRESS TEL. NO.

Salvacion Echavez PWC of Davao, Matina, Davao City

43.

PHOTO

COMMUNITY TAX CERTIFICATE NO.

Lupon, Davao OrientalISSUED AT

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


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?

If YES, give details: _____________________________________ _____________________________________ _____________________________________

Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? If YES, give details:

_____________________________________ _____________________________________ _____________________________________

If YES, give details: ________________________________ ________________________________


Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? If YES, give details:

________________________________ ________________________________

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?



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:

REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

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.

SIGNATURE (Sign inside the box)

ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)

Computer generated or xerox copy of picture

is not acceptable

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

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pdsrev2005.xls