C S F O R M 2 12 ( R e v is e d 2 0 0 5 )

PERSONAL DATA SHEET

Print legibly . Mark appropriate box es w ith " " and use separate sheet if necessary . 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME SACANDAL
FIRST NAME MOHAIRA
MIDDLE NAME UKA 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/y y y y ) 04/10/2001 16. RESIDENTIAL ADDRESS

PUROK 5, TALISAYAN
5. PLACE OF BIRTH ZAMBOANGA CIT Y ZAMBOANGA CITY
6. SEX Male Fem ale
7. CIVIL STATUS Single Widowed ZIP CODE 7000
Married Separated 17. TELEPHONE NO.
Annulled Others, specify ___________ 18. PERMANENT ADDRESS
PUROK 5, TALISAYAN
8. CITIZENSHIP FILIPINO ZAMBOANGA CITY
9. HEIGHT (m) 5.2"
10. WEIGHT (kg) 42kg ZIP CODE 7000
11. BLOOD TYPE A+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. E-MAIL ADDRESS (if any ) [email protected]

13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any ) 09066444419
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.
15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

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

FIRST NAME N/A N/A N/A

MIDDLE NAME N/A N/A N/A
OCCUPATION N/A N/A N/A
EMPLOYER/BUS. NAME N/A N/A N/A
BUSINESS ADDRESS N/A N/A N/A
TELEPHONE NO. N/A N/A N/A
(Continue on separate sheet if necessary)

26. FATHER'S SURNAME SACANDAL

FIRST NAME ROMMEL
MIDDLE NAME FRANCISCO
27. MOTHER'S MAIDEN NAME

SURNAME UKA
FIRST NAME JUBINA
MIDDLE NAME ARASAD (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST GRADE/ INCLUSIVE DATES OF
28. YEAR SCHOLARSHIP/
NAME OF SCHOOL DEGREE COURSE LEVEL/ ATTENDANCE
LEVEL GRADUATED ACADEMIC HONORS
(Write in full) (Write in full) UNITS EARNED
(if graduated) From To RECEIVED
(if not graduated)
ZAMBOANGA EAST CENT RAL
ELEMENTARY 2012 2006 2012 WITH HONOR
SCHOOL
DON PABLO LORENZO MEMORIAL
SECONDARY 2016 2012 2016
HIGH SCHOOL
VOCATIONAL / T ALISAYAN NAT IONAL HIGH GENERAL
TRADE COURSE
2018 2016 2018 WITH HONOR
SCHOOL ACADEMIC
COLLEGE BATCHELOR OF COLLEGE OF
WEST ERN MINDANAO ST AT E
SCIENCE IN AGRICULTURE
UNIVERSIT Y AGRIBUSINESS SCHOLARSHIP

GRADUATE STUDIES

(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 DATE OF
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER
CONFERMENT RELEASE

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
SALARY
30. INCLUSIVE DATES DEPARTMENT / AGENCY / OFFICE / GRADE &
POSITION TITLE STATUS OF GOV'T
M ONTHLY
(mm/dd/y y y y ) COMPANY
STEP
APPOINTM E SERVICE
(Write in full) SALARY INCREM ENT
NT (Yes / No)
From To (Write in full) (Format " 00-
0" )

05/28/2019 06/28/2019 FIELD WORKER PHILIPPINE COCONUT AUTHORITY 4,000 YES

11/22/2018 12/05/2018 HR SUPERVISOR ASSISTANT MEGA CORPORATION N/A NO

(Continue on separate sheet if necessary)

CS FORM 212 (Rev ised 2005), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
31. NUMBER OF
(Write in full) (mm/dd/y y y y ) POSITION / NATURE OF WORK
HOURS
From To

Mega Corporation 11/22/2018 12/05/2018 80 On-the-Job Training

(Continue on separate sheet if necessary)

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

INCLUSIVE DATES OF
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT ATTENDANCE NUMBER OF CONDUCTED/ SPONSORED BY
COURSES (Write in full) (mm/dd/y y y y ) HOURS (Write in full)
From To

MUSHROOM PRODUCTION 10/01/2019 10/24/2019 40 TBI

ITIK FOR LIFE STAFF AND

ITIK FOR LIFE PROGRAM 09/30/2019 09/30/2019 6
PROFESSORS

GOAT PRODUCTION 8 DEPARTMENT OF AGRICULTURE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
33. SPECIAL SKILLS / HOBBIES: 34. 35. ASSOCIATION/ORGANIZATION
(Write in full)
(Write in full)
CERTIFICATE OF PARTICIPATION IN
COMPOSING SONGS
MUSHROOM PRODUCTION
CERTIFICATE OF PARTICIPATION IN GOAT
COMPUTER LITERATE
PRODUCTION
CERTIFICATE OF PARTICIPATION IN ITIK FOR
LIFE PRODUCTION

(Continue on separate sheet if necessary)

CS FORM 212 (Rev ised 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.

NORIEZEL S. CALIGNER TALISAYAN, ZAMBOANGA CITY 9364728957

JEANROSE F. DELOS REYES CABATANGAN, ZAMBOANGA CITY 9357332598

LIANA ROSE RAMOS TALISAYAN, ZAMBOANGA CITY 9364275122

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. PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT SIGNATURE (Sign inside the box)

10/18/2019 10/18/2019
ISSUED ON (mm/dd/y y y y ) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Rev ised 2005), Page 4 of 4