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

DADIA MARISSA CAPON 01/09/1978

Male
Single Married Annulled
16. RESIDENTIAL ADDRESS 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

BORONGAN EASTERN SAMAR

Fem ale Widowed
Separated
17. TELEPHONE NO. ZIP CODE

16 SANTOL STREET AMPARO SUBDIVISION CALOOCAN CITY

1254 NONE

Others, specify ___________ 18. PERMANENT ADDRESS

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 5' 47KGS. B 2003739634 913204009495 020002336392

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

16 SANTOL STREET AMPARO SUBDIVISION CALOOCAN CITY

1425 NONE [email protected] 09287839338 4368162 277004249

II. FAMILY BACKGROUND

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

NONE NONE NONE NONE NONE NONE NONE

(Continue on separate sheet if necessary)

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

DATE OF BIRTH (mm/dd/yyyy)

NONE

/ / / / / / / /

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

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

DADIA
RICARDO BENDO (DECEASED)

/ / /

CAPON VICTORIA CATUDIO (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

BATO ELEM.SCHOOL

GRADUATE

1991 1995

GRADUATE GRADUATE

1985 1991

1991 1995

NONE NONE

EASTERN SAMAR NAT.COMPREHENSIVE GRADUATE HIGH SCHOOL

ST.MARY'S COLLEGE

BACHELOR IN ELEM.EDU.

1999

155 UNITS

1995

1999

NONE

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

LICENSURE EXAMINATION FOR TEACHER 75.00%

AUGUST 8,1999

TACLOBAN CITY

0597696

12/20/200 2

(Continue on separate sheet if necessary)

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

03/03/2008 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

PRESENT / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / /

TEACHER I

DEPARTMENT OF EDUCATION

15,649.00 STEP 2

PERMANEN YES T

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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)

INCLUSIVE EDUCATION FOR CHILDREN WITH DISABILITIES DIV. TRAINING FOR ELEMENTARY SCHOOL SCIENCE TEACHERS ON AN ENHANCEMENT OF SCIENCE

08/21/2010 10/04/2008 / / / / / / / / / / / / / / / / / / / / / / / / / /

08/28/2010 / / / / / / / / / / / / / / / / / / / / / / / / / / / /

16HRS. 8HRS.

ANGELS OF PEACE ACADEMY 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)

WATCHING MOVIES READING

NONE

NONE

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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: _____________________________________ _____________________________________ _____________________________________

b.

YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________

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

37

a. Have you ever been formally charged?

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

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: Are you a member of any indigenous group? 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: ____________________

a. b. c.

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME ADDRESS TEL. NO.

MR.MOISES R. TAMONDONG MRS. DOLORES MOGAR

AMPARO ELEM.SCHOOL AMPARO ELEM.SCHOOL

9614961 9212553563

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 contents stated herein. I trust that this information shall remain confidential. 00265958
COMMUNITY TAX CERTIFICATE NO.

Computer generated or xerox copy of picture is not acceptable

PHOTO

CALOOCAN CITY
ISSUED AT SIGNATURE (Sign inside the box)

01/04/2013
ISSUED ON (mm/dd/yyyy)

AUGUST 27,2013
DATE ACCOMPLISHED RIGHT THUMBMARK

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