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 TIPURA

FIRST NAME ERKLISTER

MIDDLE NAME DOMETITA 3. NAME EXTENSION (e.g. Jr., Sr.) N/A

16. RESIDENTIAL ADDRESS ABELLA COMPOUND CITTA GRANDE IYAM LUCENA CITY
4. DATE OF BIRTH (mm/dd/yyyy) 7/31/1989
5. PLACE OF BIRTH PAGBILAO QUEZON
6. SEX Male Fem ale
7. CIVIL STATUS
Widowed ZIP CODE 4301
Single
Married Separated 17. TELEPHONE NO. 7953831
___________
Annulled
Others, specify18. PERMANENT ADDRESS ABELLA COMPOUND CITTA GRANDE IYAM LUCENA CITY

8. CITIZENSHIP FILIPINO
9. HEIGHT (m) 1.74M
10. WEIGHT (kg) 70 KG ZIP CODE 4301
11. BLOOD TYPE 'A'' 19. TELEPHONE NO. 7953831
12. GSIS ID NO. N/A 20. E-MAIL ADDRESS (if any) eark_321@yahoo.com
13. PAG-IBIG ID NO. 12117945698 21. CELLPHONE NO. (if any) 09282867783
14. PHILHEALTH NO. 080509429085 22. AGENCY EMPLOYEE NO. 131500743
15. SSS NO. N/A 23. TIN 420480128
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME N/A 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME N/A / /

MIDDLE NA / /
OCCUPATION / /
EMPLOYER/BUS. NAME / /
BUSINESS ADDRESS / /
TELEPHONE NO. / /
(Continue on separate sheet if necessary) / /
26. FATHER'S SURNAME TIPURA / /
FIRST NAME JOSELITO / /
MIDDLE NAME MERCURIO / /
27. MOTHER'S MAIDEN NAME / /
SURNAME DOMETITA / /
FIRST NAME JOSEPHINE / /
MIDDLE NAME BATOCABE (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR

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

ELEMENTARY (if graduated)

ELEMENTARY LUCENA WEST II ELEMENTARY SCHOOL 2001 1998 2001 N/A
GRADUATE
HIGH SCHOOL
SECONDARY QUEZON NATIONAL HIGH SCHOOL 2005 2001 2005 N/A
VOCATIONAL / GRADUATE

N/A
COLLEGE
TRADE COURSE BACHELOR OF SECONDARY
MARYHILL COLLEGE EDUCATION MAJOR IN 2011 2006 2011 N/A
ENGLISH

GRADUATE STUDIES
N/A

(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
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE
MARCH 10
LICENSED FOR PROFESSIONAL TEACHER 76.60% MARYHILL COLLEGE LUCENA CITY 1234092 11/23/2013
2013

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
11/3/2017 Present FO1 ORD, BFP-NCR P14834 10 TEMPORARY YES

10/14/2016 10/3/2017 Fire Trainee NFTI CVL Laguna P14834 10 TEMPORARY YES

5/12/2015 10/13/2016 FO1/Crew Bacood FS, MFD-NCR P14834 10 TEMPORARY YES

5/10/2015 4/12/2015 FO1/OJT MFD-NCR P14834 10 TEMPORARY YES

11/25/2015 4/10/2015 FO1/Crew Bacood FS, MFD-NCR P14834 10 TEMPORARY YES

4/6/2015 11/24/2015 FO1/Crew Sta Ana FS, MFD-NCR P14834 10 TEMPORARY YES

3/17/2015 4/5/2015 FO1 MFD-NCR P14834 10 TEMPORARY YES

2/11/2015 3/16/2015 FO1 ORD, BFP-NCR P14834 10 TEMPORARY YES

11/24/2014 2/10/2015 FO1/ORIENTATION ORD, BFP-NCR P14834 10 TEMPORARY 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
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To

N/A / / / /

/ / / /

/ / / /

/ / / /

/ / / /
(Continue on separate sheet if necessary)

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

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) HOURS (Write in full)
From To
NFTI, CAMP VICENTE LIM,
FIRE BASIC RECRUIT COURSE 10/13/2016 03/10/2017 640
CANLUBANG LAGUNA

FO1/ON THE JOB TRAINING 4/12/2015 4/12/2015 MFD-NCR 5/10/2015 4/12/2015 FO1/OJT MFD-NCR P14834 10 TEMPORARY YES

BASIC RECRUIT ORIENTATION COURSE 11/24/2014 10/2/2015 ORD,BFP,NCR

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /
(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION: ASSOCIATION/ORGANIZATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full)
(Write in full)

SINGING/PLAYING GUITAR N/A N/A

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 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.

F/CSUPT BOBBY V. BARUELO GULANG-GULANG LUCENA CITY 9088847580 ID picture taken within
the last 6 months
F/INSP HENRY PASCO BALAYAN, BATANGAS 9154916289 3.5 cm. X 4.5 cm
(passport size)
F/INSP FERNANDO C. CASTILLO ANDAMAN LUCENA CITY 9189655316
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

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

CCI201406066387
COMMUNITY TAX CERTIFICATE NO.

QUEZON CITY
ISSUED AT SIGNATURE (Sign inside the box)

03/13/2017 03/13/2017
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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