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 7. CIVIL STATUS

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

01/08/1979

16. RESIDENTIAL ADDRESS

MANAGPI, CALAPAN CITY Male Fem ale

Single Married Annulled Widowed ZIP CODE Separated 17. TELEPHONE NO. Others, specify ___________
18. PERMANENT ADDRESS

MANAGPI, CALAPAN CITY, ORIENTAL MINDORO

5200 09228269818

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

FILIPINO 4'11 80 KG B 79010800396 0449-011954-02 090000594465 0433638104

19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN ZIP CODE

MANAGPI, CALAPAN CITY, ORIENTAL MINDORO

5200 NONE [email protected] 09228269818 4129878 920-202-084

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO.

MANANSALA REYNALDO BALMENCIA DRIVER SELF EMPLOYED CALAPAN CITY NONE

(Continue on separate sheet if necessary)

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

DATE OF BIRTH (mm/dd/yyyy)

RHEY BJ T. MANANSALA RHEY MJ T. MANANSALA

07/18/2008 11/06/2011 / / / / / / / / / / / / / / / / / / / /

26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME

TOLENTINO
MARIO ESPELITA

VIAS VICTORIANA BEREDO (Continue on separate sheet if necessary)

/ /

III. EDUCATIONAL BACKGROUND

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

(if graduated)

ELEMENTARY SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

MANAGPI ELEMENTARY SCHOOL MANAGPI NATIONAL HIGH SCHOOL NONE DIVINE WORD COLLEGE OF CALAPAN

ELEM. LEVEL SECONDARY

1991 1995

1985 1991

1991 1995

NONE NONE

BEED

1998

1995

1998

NONE

GRADUATE STUDIES

DIVINE WORD COLLEGE OF CALAPAN

MAED

2002

2000

2002

NONE

(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 RATING DATE OF EXAMINATION / CONFERMENT LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE

LICENSURE EXAMINATION FOR TEACHERS

77.40%

08/08/1999

ORIENTAL MINDORO

0580698

9/19/99

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. From INCLUSIVE DATES (mm/dd/yyyy) To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)
MONTHLY SALARY
SALARY GRADE & STEP INCREMENT (Format "000")

STATUS OF APPOINTMENT

GOV'T SERVICE (Yes / No)

6/1/12 6/1/11 3/14/11 6/24/10 7/1/09 7/1/08 7/1/07 9/26/03 11/19/01 10/15/01 6/15/01 6/8/00 1/25/00 / / / / / / / / / / / / / / / /

PRESENT 5/31/12 5/31/11 3/13/11 6/23/10 6/30/09 6/30/08 6/30/07 9/25/03 11/18/01 7/12/01 8/6/00 3/23/00 / / / / / / / / / / / / / / / /

TEACHER III TEACHER III TEACHER III TEACHER III TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I TEACHER I

DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION

21436.00 19658.00 17880.00 16419.00 15072.00 12328.00 11207.00 10188.00 9939.00 9939.00 9939.00 9466.00 9466.00

12'1 PERMANENT 12'1 PERMANENT 12'1 PERMANENT 12'1 PERMANENT 10'1 PERMANENT 10'1 PERMANENT 10'1 PERMANENT 10'1 PERMANENT 10'1 PERMANENT 10'1 PERMANENT 10'1 SUBSTITUTE 10'1 SUBSTITUTE 10'1 SUBSTITUTE

YES YES YES YES YES YES YES YES YES YES YES YES 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 (Write in full) INCLUSIVE DATES (mm/dd/yyyy) From To NUMBER OF HOURS POSITION / NATURE OF WORK

NONE

/ / / / /

/ / / / /

/ / / / /

/ / / / /

(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 DATES OF ATTENDANCE (mm/dd/yyyy) From To NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full)

ORIENTATION AND HANDS-ON TRAINING WORKSHOP ON THE ENHANCED BASIC EDUCATION INFORMATION SYSTEM (Ebeis) CONTINUOUS EDUCATIONAL COURSE FOR TEACHERS (ConECT) 10TH CITY DIVISION SCHOOLS PRESS CONFERENCE DIVISION MENTORS' CIRCLE MEETING DIVISION /LEVEL-3 TRAINING ON ENHANCED-BASIC EDUCATION INFORMATION SYSTEM (E-BEIS) DIVISION TRAINING ON ENGLISH LANGUAGE AND READING ENHANCEMENT PROGRAM 6TH DIVISION BOOK FESTIVAL

09/18/2012 / / / /

09/18/2012 / / / /

DEPARTMENT OF EDUCATION

05/15/2012 / /

05/16/2012 / /

16

DEPARTMENT OF EDUCATION

01/22/2012 / /

01/24/2012 / /

24

DEPARTMENT OF EDUCATION

09/03/2011 08/17/2011 / / / /

09/03/2011 08/17/2011 / / / /

8 8

DEPARTMENT OF EDUCATION DEPARTMENT OF EDUCATION

08/18/2010 / /

08/20/2010 / /

36

DEPARTMENT OF EDUCATION

11/27/2009 / /

11/28/2009 / /

16

DEPARTMENT OF EDUCATION

(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)

WRITING STORIES COMPUTER LITERATE

NONE

PHILIPPINE PUBLIC SCHOOL TEACHERS ASSOCIATION

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

36. a.

Are you related by consanguinity or affinity to any of the following : 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? Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?
YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________ YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________

b.

37

a. Have you ever been formally charged?

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

YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO

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?

If YES, give details: ________________________________ ________________________________

YES NO

40.

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

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?
b. c.

Are you differently abled? 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 consanguinity or affinity to applicant / appointee) NAME ADDRESS TEL. NO.

JAMES T. ZAMORA ALFONSO F. GALICHA AUREA MARIE A. VILLA DEL REY

43.

CALAPAN SOUTH DISTRICT OFFICE BUCAYAO ELEMENTARY SCHOOL MANAGPI ELEMENTARY SCHOOL

09391322046 09198454465 09176128370

ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size)

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.

Computer generated or xerox copy of picture is not acceptable

PHOTO

23412354
COMMUNITY TAX CERTIFICATE NO.

CALAPAN CITY
ISSUED AT SIGNATURE (Sign inside the box)

01/03/2013
ISSUED ON (mm/dd/yyyy)

January 31, 2013

DATE ACCOMPLISHED RIGHT THUMBMARK

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