CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

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

I. PERSONAL INFORMATION
2. SURNAME MEJICO
FIRST NAME VINCENT
MIDDLE NAME MALDO 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 01/14/2006 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH Banton,lombron 178 M. De Castro St. Bagong Barrio Caloocan City

6. SEX Male ✘ Female

7. CIVIL STATUS Single Separated ZIP CODE 1400

✘ Married Widowed 17. TELEPHONE NO.

Others specify:
Annuled 18. PERMANENT ADDRESS
________________________
8. CITIZENSHIP Filipino 178 M. De Castro St. Bagong Barrio Caloocan City

9. HEIGHT (m) 1.62m

10. WEIGHT (kg) 64kg ZIP CODE 1400

11. BLOOD TYPE O 19. TELEPHONE NO.

12. GSIS ID NO. 2004007288 20. E-MAIL ADDRESS (if any)Joenazki_23@yahoo. Com

13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any)09395325474

14. PHILHEALTH NO. None 22. AGENCY EMPLOYEE NO.4543890

15. SSS NO. None 23. TIN 222 263 438

II. FAMILY BACKGROUND

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

FIRST NAME Chrizelle Jean B. Velasquez 07/05/95

MIDDLE NAME Chrizalette Joie B. Velasquez 07/09/06

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate form if necessary)

26. FATHER'S SURNAME MEJICO

FIRST NAME PEPITO

MIDDLE NAME FANCUBIT

27. MOTHER'S MAIDEN NAME

SURNAME ACOSTA

FIRST NAME ROSEMARIE

MIDDLE NAME MALDO YEAR (Continue on separate form if necessary)

GRADUATE
III. EDUCATIONAL BACKGROUND D
HIGHEST
GRADE/ LEVEL/ INCLUSIVE DATES OF
28. NAME OF SCHOOL DEGREE COURSE SCHOLARSHIP/
UNITS ATTENDANCE
LEVEL (Write in ACADEMIC
EARNED
full) From To HONORS RECEIVED
(if not
graduated)
(if
ELEMENTARY M.KALAW ELEMENTARY SCHOOL 1983
graduated
)
SECONDARY /
VOCATIONAL PARANG NATIONAL HIGH SCHOOL 1987

Bachelor of
COLLEGE Science in
TRADE COURSE Secondary 1999 Dean Lister
Education. Maj.
In Filipino

M. A. in
GRADUATE STUDIES Education maj.
Dr. In 15 2005 2006
Administration
and Supervision

(Continue on separate form if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/
EXAMINATIO
BAR) UNDER SPECIAL LAWS/ CES/ RATING PLACE OF EXAMINATION / CONFERMENT
N/ NUMBER DATE OF
CSEE
CONFERMENT RELEASE

Lisensure Examination for Teacher 75.00% Aug. 27, 2000 Manuel L. Quezon University 0752965 Oct. 4, 2000

(Continue on separate form if necessary)

GOV'T
V. WORK EXPERIENCE (Include private employment. Start from your current work) SERVICE
SALARY
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / GRADE & STATUS OF
(mm/dd/yyyy) COMPANY MONTHLY STEP
APPOINTMEN
(Write in SALARY INCREMENT
T
(Format "00-
From To (Write in full) full) 0")
(Yes /
Permanen No)
6/18/2010 present Filipino Teacher Macario B. Asistio Sr. High School YES
t

Bagong Barrio National High 10,405.0

6/8/2009 3/31/2010 Finlipino Teacher LSB YES
School 0

Elem. & High Filipino 12,600.0 Permanen

June, 2000 5/27/2009 Dr. Carlos S. Lanting College NO
Teacher 0 t

(Continue on separate form if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4
Oct. 4, 2000
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY O
INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION NUMBER
(Write in full) POSITION / NATURE OF WORK
(mm/dd/yyyy) OF HOURS
From To

(Continue on separate form if necessary)

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

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

Summer 2011 School Based in-Service Training For 5/30/2011 6/3/2011 40 hrs Macario B.
Teachers Asistio Sr. High School

9/27/2008 APSA
Istratehiya ng Pagtuturo ng Wika at Panitikan Filipino Centrex

5/5/2007 Dr.
The Innovative Mind-Body-Voice Carlos S. Lanting College

6/10/2005 Dr.
ISO 9001: 2000 Familiarization Seminar Carlos S. Lanting College

7/23/2005
Personal and Professional Effectiveness Dr. Carlos
S. Lanting College
7/23/2005
Values Formation and Work Ethics Dr. Carlos S. Lanting
College
Showcasing Integration in the 2000 Basic Curriculum 1/24/2004
via New Teaching Strategy Phoenix Publishing
House
11/15/2003
Teaching for Relevance Rex Bookstore, Inc

(Continue on separate form 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)

Computer Literate

Knowledgeable in Clerical Job

Art Works

Playing Volleyball

(Continue on separate form 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 If YES, give details:
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? ____________________________________
_
b. Within the fourth degree (for Local Government Employees): ____________________________________
YES ✘ NO
appointing authority or recommending _
If YES, give details:
authority where you will be appointed? ____________________________________
_____________________________________________
___________________
____________________________________
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, YES ✘ NO
decree, ordinance or 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, YES ✘ NO
termination, end of term, finished contract, AWOL or phased out, in If YES, give details:
the public or private sector? _____________________________________________
________________________________
__________________
__ ________________

40. Have you ever been a candidate in a national or local election (except YES ✘ NO
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.

Ma. Victoria David M. De Castro St. Bagong Barrio, Cal City

637 10 14
ID picture taken within
the last 6 months
Ptr. Lee Oliver 302 PPI Bldg. EDSA Bagong Barrio Cal City
9192357455 3.5 cm. X 4.5 cm
(passport size)
Virginia A. Diokno Dr. Carlos S. Lanting College 9094537655
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, or xerox copy of picture
and is a true, correct and complete statement pursuant to the provisions of is not acceptable

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

16201843

COMMUNITY TAX CERTIFICATE NO.

Caloocan City
ISSUED AT SIGNATURE (Sign inside the box)

3/4/2011
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4