2i> CAREER SERV1CEJ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (If �)

' SPECIA L LAWS/ CES/ CSEE

RATING
EXAMINATION / PLACE OF EXAMINATION/ CONFERMENT
(If ,wltcable) Dale of
BARANGAYELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER
Vabdty

PRC NOV.5-7,2019 CEBU CITY 0036227 10/03/2023

DRIVER'S LICENSE LTO/OIPOLOG CITY JO1-17-000966 OCT.3.2021

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128 INCLUSIVE DATES WJlff/JOfJ/PAY

GAAOE(d
(rrrn/ddfyyyy) POSITION TITLE DEPARTMENT/ AGENCY/ OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Wnle In full/Do nol abbreviate) (Wnte in full/Do nol abbr0V1ate) SA!.ARY
(F°"""''OO-O'Y
APPOUffi,ENT
(YIN)
Frcrn To tlCAEMENT

OFFICE OF THE PROVINCIAL

March 3,2020 July 30, 2021 AGRICULTURIST AGRICULTURIST, ZAMBOANGA DEL 500/Day JOB ORDER YES
NORTE
PHILIPPINE SCIENCE HIGH SCHOOL,
November 5, CONTRACT
June 15, 2022 SPECIAL SCIENCE TEACHER 1 ZAMBOANGA PENINSULA REGIONAL P28,276.00 YES
2021 OF SERVICE
CAMPUS

I
(Continue on np•at• '11Ht ff-..ry)
,........_
SIGNATURE DATE July 18, 2022 CS FORM 212 (Revised 2017), Page 2 of4
�
_..._
 .-
VI. VOLUNTARY
... WORK OR INVOLVEMENT IN CIVIC I NON-GOVERNMENT I PEOPLE I VOLUNTARY ORGANIZATIONIS
' INCLUSIVE DATES
29 NAME & ADDRESS OF ORGANIZATION
(mm/dli'yyyy) NJM8ER Of HOI.RS POSITION/ NATURE OF WORK
(Wnteinfull)
From To

NIA NIA N/A N/A NIA

(Conlnue on se,,.,afe sheet If nece.u,yj

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED

the-.,,, L&Dlhlalng IIIHII for 1M ust 1M P} -• tor DMslon ChleU&ICIIM'IClno(lt(illl ,-illons/
(Sim from the most nant L&Dllrlllnlng prog,Mn and Inc/UM only

INCLUSIVE DATES Of T)lleofLO

TITLE Of LEARNlNG AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE (� CONDUCTED/ SPONSORED BY
>lJIIBEROFHOUIS
(Wrrte 1nMI) (nvnldd'yyyy) � (Wn1a infulQ
Tectncallelc)
From To

NATIONAL CERTIFICATE II In ORGANIC AGRICULTURE PRODUCTION FEB.13,2020 TESDA

MICROSOFT OFFICE PRODUCTIVITY SUITE DEC.12,2019 JAN.18,2020

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS/ RECOGNITION MEMBERSHIP IN ASSOCIATIONKJRGANIZATION
31 SPECIAL SKILLS and HOBBIES 32.
(Wnle,nfuH) 33
(Wnle in full)

AIR LAYERING/MARCOT CHURCH CHOIR

BUDDING AGGIEES CLUB-SILLIMAN UNIVERSITY

COMPUTER LITERATE SILINGAN ZANORTE SILLIMANITES

SKILL IN COMMUNICATION

PLAYING MUSICAL INSTRUMENT

DRIVING

SINGING
-
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(Continue on separw, shftt ff neceSUJY)

SIGNATURE ( :::..\-1\'
DATE July 18, 2022 CS FORM 212 {Revistd 2017), Plfl" 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
�chief of)Jureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? 0 YES 0 NO
b. within the fourth degree (for Local Government Unit - Career Employees)? 0 YES 0 NO
If YES, give details:

35. a. Have you ever been found guilty of any administrative offense? 0 YES 0 NO
If YES, give details:

b. Have you been criminally charged before any court? 0 YES 0 NO

If YES, give details:
Date Filed: -------
Status of Casals:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by 0 NO
0 YES
any court or tribunal? If YES, give details:

37. Have you ever been separated from the service in any of the following modes: resignation, □ YES 0NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased out If YES, give details:
(abolition) in the public or private sector?
38. a. Have you ever been a candidate in a national or local election held within the last year (except 0 YES 0 NO
Barangay election)? If YES, give details: __________

b. Have you resigned from the government service during the three (3)-month period before the last 0 YES 0 NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
Have you acquired the status of an immigrant or permanent resident of another country? 0
39. YES 0 NO
If YES, give details (country):

40. 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? 0 YES 0 NO
If YES, please specify:
b. Are you a person with disability? 0 YES 0 NO
If YES, please specify ID No:
c. Are you a solo parent? 0 YES 0 NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

HON. ALBELLO M.PADAYHAG- PUNTA, BARANGAY
PUNTA,DIPOLOG CITY
CHAIRMAN
DR. EDWIN C. CUBELO - SILLIMAN UNIVERSITY COLLEGE
DUMAGUETE CITY 9173224420
OF AGRICUTURE (DEAN
JUDGE KENNETH P. ROSAL

I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I
authorize the agency head I authorized representative to verify/validate the contents staled herein. I agree that any
misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal easels t'HOIO
against me.

Government Issued ID �.e Pass.port, GSIS. sss. PRC. llrMll's Uceose. etc.)
!
PLEASE INDICATE ID Number and Date of Issuance
IG011ernment Issued 10: PRC

!ID/License/Passport No.: 0036227

Date Accomplished �ight Thumbmari(

I / ..·•t
�fore me this J v:½:) l jI U? 2-,, , affiant exhibiting his/her validly issued government ID as indicated above.

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