Pdsrev 2005

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
B | A |W | A | L | A | N |
M| A | R | G | A |R 06
Male
Single Married Annulled
| | / 1953
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
| |
| |
| |
| |
| |
| |
| | |
| | |
| | |
| | |
| | |
| | |
| | |
|I
|T |A | / 10
C | A | U| S | A | R |E | N |
Negros Occidental
Fem ale
Widowed Separated
3. NAME EXTENSION (e.g. Jr., Sr.) | | | | | |
16. RESIDENTIAL ADDRESS
168 Tamakan, Amadeo,Cavite
ZIP CODE 17. TELEPHONE NO.
4119
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 158 65 0 006-0031-2003-3 0003-095955-01 08-000026252-1

19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN ZIP CODE
[email protected] 09266631032 0159480 129-901-476
II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. (Continue on separate sheet if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME Bawalan Juliana Leachon (Continue on separate sheet if necessary)
Bawalan Procinio Aure Farmer
25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH (mm/dd/yyyy)
Bawalan, Abegail Bawalan, Aileen Bawalan, April
06 / 01 / 1982
10/18/1983 01/17/1987 / / / / / / / / / / / / / / / / / / / /
Causaren
Primo Montoya
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
Halang Banay-Banay Elem. School Dasma Nat'l High Sch - Main
1993 1996
1987 1993
1993 1996
De La Salle University- Dasma
BSE-History
2001
1996
2001
GRADUATE STUDIES
De La Salle University- Dasma Laguna Northwestern College
MATSS Admin & Supervision

(Continue on separate sheet if necessary)
9 UNITS 45 units
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
79.00%
Aug. 21, 2001
UE - Recto
747454
1-18-2002
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)
/ / / / / / / / / / / / / / / / / / / /
/ / / / / / / / / / / / / / / / / / / /
/ / / / / / / / / / / / / / / / / / / /
/ / / / / / / / / / / / / / / / / / / /
(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
/ / / / /
/ / / / /
/ / / / /
/ / / / /
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)
/ / / / / / / / / / / / / / /
/ / / / / / / / / / / / / / /
/ / / / / / / / / / / / / / /
/ / / / / / / / / / / / / / /
VIII. OTHER INFORMATION

33. SPECIAL SKILLS / HOBBIES: 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full) 35. MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
(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: _____________________________________ _____________________________________ _____________________________________
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.
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.
Computer generated or xerox copy of picture is not acceptable
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign inside the box)
/
DATE ACCOMPLISHED RIGHT THUMBMARK
ISSUED ON (mm/dd/yyyy)
CS FORM 212 (Revised 2005), Page 4 of 4

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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

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

16. RESIDENTIAL ADDRESS

168 Tamakan, Amadeo,Cavite

ZIP CODE 17. TELEPHONE NO.

Others, specify ___________ 18. PERMANENT ADDRESS

Filipino 158 65 0 006-0031-2003-3 0003-095955-01 08-000026252-1

[email protected] 09266631032 0159480 129-901-476

II. FAMILY BACKGROUND

Bawalan Procinio Aure Farmer

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

DATE OF BIRTH (mm/dd/yyyy)

Bawalan, Abegail Bawalan, Aileen Bawalan, April

III. EDUCATIONAL BACKGROUND

ELEMENTARY SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

Halang Banay-Banay Elem. School Dasma Nat'l High Sch - Main

De La Salle University- Dasma

De La Salle University- Dasma Laguna Northwestern College

MATSS Admin & Supervision

IV. CIVIL SERVICE ELIGIBILITY

Licensure Examination for Teachers

Aug. 21, 2001

(Continue on separate sheet if necessary)

GOV'T SERVICE (Yes / No)

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

(Continue on separate sheet if necessary)

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

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________

a. Have you ever been formally charged?

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

If YES, give details: ________________________________ ________________________________ YES NO

If YES, give details: ________________________________ ________________________________

Computer generated or xerox copy of picture is not acceptable

COMMUNITY TAX CERTIFICATE NO.

SIGNATURE (Sign inside the box)

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

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YES NO If YES, give details: ___________________ _ ___________________

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