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

MENDOZA CLINT MIGUEL 11/23/1988

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

NONE

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

STO.TOMAS,LUBAO,PAMPANGA
Fem ale Widowed Separated
17. TELEPHONE NO. ZIP CODE

612 CONCEPCION,LUBAO,PAMPANGA

2005 N/A

*
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.

Married
Annulled

Others, specify ___________ 18. PERMANENT ADDRESS

FILIPINO 1.65 M 80 KG O NONE NONE 07-050628360-2 02-2663453-5 NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A)
(Continue on separate sheet if necessary) 19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN ZIP CODE

612 CONCEPCION,LUBAO,PAMPANGA

2005 N/A mendozaclint@rocketmail.com 0927-974-6887 1-25-2001 369-280-482-745-000

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A)

None (N/A) None (N/A) None (N/A) None (N/A) None (N/A) None (N/A) / /

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

MENDOZA AGUSTINO BATAC

8/28/1949 / / / / / /

MIGUEL LORETA DIONISIO

(Continue on separate sheet if necessary)

4/19/1948 / /

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

LUBAO CENTRAL ELEMENTARY SCHOOL ELEMENTARY HOLY ROSARY ACADEMY NONE (N/A) UNIVERSITY OF THE ASSUMPTION BS-BA Major in Marketing SECONDARY

2001 2005

GRADUATED GRADUATED

1995 2001

2001 2005

2ND HONORABLE MENTION LEGIONARY OF THE YEAR

2009

GRADUATED

2005

2009

PRESIDENT'S LISTER

GRADUATE STUDIES

HOLY ANGEL UNIVERSITY

MBM

N/A

36 UNITS

2009

PRESENT

(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

NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A)

N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A

(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)

6/13/2011 3/2/2011 8/25/2009 4/14/2009

PRESENT 4/7/2011 2/25/2011 8/8/2009

DON HONORIO VENTURA STATE UNIVERSITY/BACOLOR PAMPANGA MANAGEMENT TRAINEE FOR TOKYO FASHION BOUTIQUE, STORE MANAGER I INC./GIORDANO SM PAMPANGA FRESH N' FAMOUS, INC./GREENWICH ASSISTANT STORE MANAGER SM CLARK GUAGUA RURAL BANK/GUAGUA MANAGEMENT TRAINEE PAMPANGA COLLEGE INSTRUCTOR NOTHING FOLLOWS

PART-TIME YES PROBATIO NO NARY REGULAR NO

PROBATIO NO NARY

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

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

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

/ / / / / / / / / / / / / / /
(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 (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A)

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

(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)

NATIONAL ECONOMICS CONVENTION: WHY IS THE PHILIPPINES IS STILL POOR NATIONAL ENTREPRENEURSHIP SEMINAR TEACHING METHODS SEMINAR IT'S ALL ABOUT MARKETING SEMINAR PUBLIC SPEAKING MODULE PROFIT AND LOSS APPRECIATION WORKSHOP KITCHEN MANAGEMENT PROGRAM FOUNDATIONS OF STORE MANAGEMENT UACSC SUMMER PLANNING INSTITUTIONAL STRATEGIC PLANNING II

3/8/2013 3/1/2013 2/22/2013 2/18/2013 8/28/2010 8/16/2010 4/28/2010 8/25/2009 5/9/2008 4/21/2008

3/8/2013 3/1/2013 2/22/2013 2/18/2013 8/28/2010 8/17/2010 4/29/2010 10/14/2009 5/11/2008 4/22/2008 1/31/2007 12/3/2006 10/25/2006 8/28/2006 11/3/2005 8/8/2005

8 8 5 5 8 16 16 320 24 16 4 24 4 24 24 8

UNIVERSITY OF SANTO TOMAS GO-NEGOSYO ANGELES UNIVERSITY FOUNDATION D.H.V.T.S.U. CVJ TRAINING CENTER FRESH N' FAMOUS, INC. FRESH N' FAMOUS, INC. FRESH N' FAMOUS, INC. UACSC UNIVERSITY OF THE ASSUMPTION UNIVERSITY OF THE ASSUMPTION YMCA MANILA, INC. UNIVERSITY OF THE ASSUMPTION UNIVERSITY OF THE ASSUMPTION YMCA MANILA, INC. UNIVERSITY OF THE ASSUMPTION

HONING INTRA AND INTERPERSONAL RELATIONSHIP SKILLS 1/31/2007 32TH NATIONAL CONGRESS OF COLLEGE STUDENTS CONVERSATIONAL ENGLISH SEMINAR RELIGARE' 06 (LEADERSHIP SEMINAR) 31ST NATIONAL CONGRESS OF COLLEGE STUDENTS COPING MECHANISMS IN NEW ENVIRONMENT 12/1/2006 10/25/2006 8/25/2006 11/01/005 8/8/2005

NOTHING FOLLOWS
(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)

PLAYING CHESS READING WRITING COMPUTER LITERATE SURFING THE INTERNET

MOST PUNCTUAL OFFICER, UACSC, 2008 MOST PRODUCTIVE OFFICER, UACSC, 2008 LEGIONARY OF THE YEAR, 2005 1ST RUNNER-UP, MR.H.R.A. 2004 5TH IN CHESS, DISTRICT CONTEST, 2001
(Continue on separate sheet if necessary)

NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A) NONE (N/A)
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: _____________________________________ _____________________________________ _____________________________________ YES NO

b.

37

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: ________________________________ ________________________________
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: 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.

GIANNA MARIA ARCEO MARK ANTHONY PABUSTAN ALEX CASTRO

43.

CITY OF SAN FERNANDO (P) MEXICO CITY, PAMPANGA MEXICO CITY, PAMPANGA

045-963-5177 0933-3322999 0922-3627342

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

COMMUNITY TAX CERTIFICATE NO.

LUBAO, PAMPANGA
ISSUED AT SIGNATURE (Sign inside the box)

10/30/2013
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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

If YES, give details: _____________________________________ _____________________________________ _____________________________________

If YES, give details: _____________________________________ _____________________________________ _____________________________________ If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________ If YES, give details: ________________________________ ________________________________

If YES, give details: ________________________________ ________________________________

If YES, give details: ________________________________ ________________________________

If YES, please specify: ____________________ If YES, please specify: ____________________ If YES, please specify: ____________________

intee)

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