CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15344137

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

I. PERSONAL INFORMATION
2. SURNAME ZALDIVAR
FIRST NAME NELCAN
MIDDLE NAME DORING 3. NAME EXTENSION (e.g. Jr., Sr.) JR.
16. RESIDENTIAL ADDRESS Purok Rose, Songcuya, DIPLAHAN, ZAMBOANGA
4. DATE OF BIRTH (mm/dd/yyyy) 02 / 25 / 1997
SIBUGAY
Songcuya, Diplahan
5. PLACE OF BIRTH
Zamboanga Sibugay
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 7039
Married Separated
17. TELEPHONE NO. N/A
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Purok Rose, Songcuya, DIPLAHAN, ZAMBOANGA
SIBUGAY
8. CITIZENDSHIP Filipino
9. HEIGHT (m) 1.5748
10. WEIGHT (kg) 60 ZIP CODE 7039
11. BLOOD TYPE AB+ 19. TELEPHONE NO. N/A
12. GSIS ID NO. N/A 20. EMAIL ADDRESS (if any) nelcanzaldivar@gmail.com
13. PAGIBIG ID NO. N/A 21. CELLPHONE NO. (if any) 09979663137
14. PHILHEALTH NO. N/A 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. N/A 23. TIN N/A

II. FAMILY BACKGROUND

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

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME ZALDIVAR

FIRST NAME NELCAN SR.

MIDDLE NAME ANTICE

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME DORING

FIRST NAME CONCEPCION

MIDDLE NAME DAQUE

III. EDUCATIONAL BACKGROUND

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

SONGCUYA ELEMENTARY 2003-06- 2009-03-

ELEMENTARY 2009 6 Valedictorian
SCHOOL 03 29

LINDANG NATIONAL HIGH 2009-06- 2014-03-

SECONDARY 2014 Valedictorian
SCHOOL 04 27

VOCATIONAL/ TRADE
N/A N/A N/A N/A N/A N/A
COURSE

BACHELOR OF
SIBUGAY TECHNICAL TECHNICAL 2014-06- 2018-03-
COLLEGE 2018 Full Scholar
INSTITUTE INCORPORATED TEACHERS 03 27
EDUATION

ZALDIVAR, NELCAN DORING - T15344137 CS FORM 212 (Revised 2005), Page 1 of 4

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

GRADUATE STUDIES

ZALDIVAR, NELCAN DORING - T15344137 CS FORM 212 (Revised 2005), Page 2 of 4

IV. CIVIL SERVICE ELIGIBILITY
29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE

LET (LICENSURE EXAMINATION FOR

83.20 09 / 30 / 2018 Pagadian City 1681122 12/07/2018
TEACHER)

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

N/A N/A N/A N/A N/A 0-0 N/A No

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

31. INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy) NUMBER OF
POSITION / NATURE OF WORK
(Write in full) HOURS
From To

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

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

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

SIBUGAY TECHNICAL
TRAINERS AND ASSESSORS METHODOLOGY COURSE 10 / 10 / 2015 03 / 11 / 2016 264
INSTITUTE INCORPORATED

VIII. OTHER INFORMATION

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

COMPUTER LITERATE N/A N/A

ZALDIVAR, NELCAN DORING - T15344137 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
has immediate supervision over you in the Office, Bureau or Department where you will be If YES, give details:
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.

Hon. Melvin Songcuya Songcuya, Diplahan Zamboanga Sibugay 09355755287

Ptr. Federico B. Songcuya Songcuya, Diplahan Zamboanga Sibugay 09355591582

Mrs. Gina C. Saluba Lower Taway, Ipil, Zamboanga Sibugay 09268400030

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.
X
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that
this information shall remain confidential. PHOTO

31349256

COMMUNITY TAX CERTIFICATE NO.

Songcuya, Diplahan ZS

ISSUED AT SIGNATURE (Sign inside the box)

2019-02-06 06 / 02 / 2019

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

ZALDIVAR, NELCAN DORING - T15344137 CS FORM 212 (Revised 2005), Page 4 of 4