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 PALACA

FIRST NAME GERMELYN

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

4. DATE OF BIRTH (mm/dd/yyyy) 11/06/1985 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH PISAAN SAN FRANCISCO AGUSAN DEL SUR PUROK 3 PISAAN SAN FRANCISCO AGUSAN DEL SUR
6. SEX Male Fem ale
7. CIVIL STATUS Single Widowed ZIP CODE 8501
Married Separated
17. TELEPHONE NO. N/A
Others, specify ___________
Annulled 18. PERMANENT ADDRESS

8. CITIZENSHIP FILIPINO PUROK 3 PISAAN SAN FRANCISCO AGUSAN DEL SUR

9. HEIGHT (m) 1.57
10. WEIGHT (kg) 60 ZIP CODE 8501
11. BLOOD TYPE O" 19. TELEPHONE NO. N/A
12. GSIS ID NO. N/A 20. E-MAIL ADDRESS (if any) germelynpalaca@gmail.com
13. PAG-IBIG ID NO. N/A 21. CELLPHONE NO. (if any) 09078664565
14. PHILHEALTH NO. 23-001424491-9 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. 082-908-6548 23. TIN 748-422-488-000
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME PALACA 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME RUBEN KEVIN D. PALACA 09/26/2006

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

26. FATHER'S SURNAME DE ASIS

FIRST NAME JERRY
MIDDLE NAME ABAO
27. MOTHER'S MAIDEN NAME

SURNAME ASNA
FIRST NAME CARMELITA
MIDDLE NAME PILOS (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 full) ACADEMIC HONORS
UNITS EARNED
(Write in full) From To RECEIVED
(if not graduated)

(if graduated)
ELEMENTARY PISAAN ELEMENTARY SCHOOL ELEMENTARY 1998 1993 1998

AGUSAN SUR NATIONAL HIGH

VOCATIONAL
SECONDARY /
SCHOOL
SECONDARY 2002 1999 2002

COLLEGE TRADE BACHELOR OF

COURSE SAN FRANCISCO COLLEGES ELEMENTARY 2017 2013 2017
EDUCATION

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

LICENSURE EXAMINATION FOR TEACHER 78.40% 03/24/2019 CAGAYAN DE ORO CITY 1761931 06/10/2019

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
SALARY GOV'T SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / GRADE &
(mm/dd/yyyy) MONTHLY STEP STATUS OF
COMPANY SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-
From To 0")
(Yes / No)
PISAAN CENTRAL ELEMENTARY
10/5/2020 8/31/2021 VOLUNTEER TEACHER VOLUNTEER YES
SCHOOL
PISAAN CENTRAL ELEMENTARY
6/3/2019 4/2/2020 VOLUNTEER TEACHER SCHOOL
VOLUNTEER YES

PISAAN CENTRAL ELEMENTARY

6/4/2018 4/5/2019 VOLUNTEER TEACHER SCHOOL
VOLUNTEER 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

(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

DEPARTMENT OF EDUCATION PISAAN

LEARNING DELIVERY MODALITIES COURSE 2 09/16/2020 09/20/2020 40 HRS.
CENTRAL ELEMENTARY SCHOOL

GOING BEYOND READING AND WRITING:5 DAYS SCHOOL-BASED TRAINING DEPARTMENT OF EDUCATION PISAAN
03/01/2021 03/05/2021 40 HRS.
ON LITERACY INSTRUCTION (FILIPINO & ENGLISH) CENTRAL ELEMENTARY SCHOOL

4 DAYS SCHOOL-BASED TRAINING ON PEDADOGICAL RETOOLING DEPARTMENT OF EDUCATION PISAAN

10/19/2020 10/22/2020 32 HRS.
INSTRUCTION IN MATHEMATICS, LANGUAGES AND SCIENCE (PRIMALS) CENTRAL ELEMENTARY SCHOOL

3 DAYS RETOOLING ON INDIGENOUS EDUCATION (IPED) FOR NEWLY-HIRED DEPARTMENT OF EDUCATION DIVISION OF
12/16/2019 12/18/2019 24 HRS.
TEACHERS TEACHING IN INDIGENOUS CULTURAL COMMUNITIES (ICCS) AGUSAN DEL SUR

INFORMATIC COMPUTER INSTITUTE OF

MODULAR TAINING PROGRAM IN PERSONAL COMPUTER OPERATION 11/18/2017 12/17/2017 20 HRS.
AGUSAN DEL SUR

TECHNICAL EDUCATION AND SKILLS

ENGLISH LANGUAGE SKILLS TRAINING PROGRAM NC 1 7/11/2016 9/25/2016 100 HRS.
DEVELOPMENT AUTHORITY

(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)
CERTIFICATE OF PARTICIPATION
WOMEN'S ASSOCIATION OF SAN
TYPING/SINGING TECHNICAL GROUP SUPPORT DURING 5 DAYS SCHOOL-BASED
FRANCISCO AGUSAN DEL SUR
TRAINING ON LITERACY INSTRUCTION (ENGLISH & FILIPINO)

CERTIFICATE OF PARTICIPATION
CHAIRMAN IN PROGRAM AND CERTIFICATES COMMITTE DURING WOMEN'S ASSOCIATION OF SAN
5 DAYS SCHOOL-BASED TRAINING ON LITERACY INSTRUCTION FRANCISCO AGUSAN DEL SUR
(ENGLISH & FILIPINO)

TAGAPAGSANAY SA PATIMPALAK NA MADULANG PAGKUKWENTO WOMEN'S ASSOCIATION OF SAN

(1ST PLACE) FRANCISCO AGUSAN DEL SUR

CERTIFICATE OF COMMENDATION COACH WOMEN'S ASSOCIATION OF SAN

FOR COOKING CONTEST DURING NUTRITION MONTH (2ND PLACE) FRANCISCO AGUSAN DEL SUR

CERTIFICATE OF RECOGNITION MASTER WOMEN'S ASSOCIATION OF SAN

OF CEREMONY DURING MR. & MS. NUTRITION 2019 FRANCISCO AGUSAN DEL SUR

INNOVATION IN TEACHING LEARNING: UTILIZING ELECTRONIC WOMEN'S ASSOCIATION OF SAN

TEACHING MATERIALS IN VIRTUAL CLASSES FRANCISCO AGUSAN DEL SUR

CREATING ENGAGING LESSONS THROUGH THE USE OF WOMEN'S ASSOCIATION OF SAN

SUPPLEMENTAL MATERIALS FRANCISCO AGUSAN DEL SUR

WOMEN'S ASSOCIATION OF SAN

SOCIAL EMOTIONAL LEARNING OF STUDENTS AT HOME
FRANCISCO AGUSAN DEL SUR
(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.
YES NO
Within the third degree (for National Government Employees):
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,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL YES NO
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)?
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.

GILBERT R. LAYAO, ELEMENTARY SCHOOL PRINCIPAL 1 PISAAN SAN FRANCISCO AGUSAN DEL SUR 9383866234
ID picture taken within
the last 6 months
NERIE M. GERVACIO, MASTER TEACHER 1 PATIN-AY PROSPERIDAD AGUSAN DEL SUR 9124685971 3.5 cm. X 4.5 cm
(passport size)

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
is not acceptable
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

11685589
COMMUNITY TAX CERTIFICATE NO.

MTO- SAN FRANCISCO ADS

ISSUED AT SIGNATURE (Sign inside the box)

2/3/2021 03/11/2021
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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