Pds Sample

CS Form No.
212
PERSONAL DATA SHEET

Revised 2017
WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME OBSIOMA
NAME EXTENSION (JR., SR) N/A
FIRST NAME RANDY
MIDDLE NAME NACALABAN

3. DATE OF BIRTH
(mm/dd/yyyy)
03/4/1971 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH OPOL, MISAMIS ORIENTAL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS BLOCK 41, LOT 14 STO.NIÑO
Widowed Separated House/Block/Lot No. Street
Other/s:
KISANLU SUBDIVISION IPONAN
Subdivision/Village Barangay
7. HEIGHT (m) 1.73m CAGAYAN DE ORO CITY MISAMIS ORIENTAL

City/Municipality Province
8. WEIGHT (kg) 80kg ZIP CODE 9000
9. BLOOD TYPE AB 18. PERMANENT ADDRESS BLOCK 41, LOT 14 STO.NIÑO

House/Block/Lot No. Street
10. GSIS ID NO. 2003548296 KISANLU SUBDIVISION IPONAN

Subdivision/Village Barangay
11. PAG-IBIG ID NO. 1080-0237-6730 CAGAYAN DE ORO CITY MISAMIS ORIENTAL

City/Municipality Province
12. PHILHEALTH NO. 19-000516189-8 ZIP CODE 9000
13. SSS NO. N/A 19. TELEPHONE NO. N/A
14. TIN NO. 177-273-947 20. MOBILE NO. 09271334782
15. AGENCY EMPLOYEE NO. O94007 21. E-MAIL ADDRESS (if any) jongobsioma@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME OBSIOMA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME SHEILA MARIE

NAME EXTENSION (JR., SR) N/A SHAIRA VANESSA O. OBSIOMA 11/15/1996
MIDDLE NAME ONGKIATCO
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME OBSIOMA

NAME EXTENSION (JR., SR) N/A
FIRST NAME ROMEO
MIDDLE NAME JABLA
25. MOTHER'S MAIDEN NAME
SURNAME NACALABAN
FIRST NAME EVA
MIDDLE NAME SABELLINA (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND

SCHOLARSHIP/
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE HIGHEST LEVEL/
YEAR ACADEMIC
LEVEL UNITS EARNED
(Write in full) (Write in full) GRADUATED HONORS
(if not graduated)
RECEIVED
From To
ELEMENTARY OPOL CENTRAL SCHOOL PRIMARY 1978 1984 N/A 1984 N/A
SECONDARY LICEO DE CAGAYAN HIGH SCHOOL 1984 1988 N/A 1988 N/A
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE
XAVIER UNIVERSITY BACHELOR OF SCIENCE IN CUSTOMS

COLLEGE 1988 1993 N/A 1993 N/A
CAGAYAN CAPITOL COLLEGE ADMINISTRATION
GRADUATE STUDIES MEDINA COLLEGE MASTER IN PUBLIC ADMINISTRATION 2018 2019 27 UNITS N/A N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE FEBRUARY 28, 2024
CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity
CSC - FIRE OFFICER ELIGIBILITY 80.82 08/14/2005 CAGAYAN DE ORO CITY N/A N/A

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
GRADE (if GOV'T
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
applicable)& STEP SERVICE
(Write in full/Do not abbreviate) (Write in full/Do not abbreviate) SALARY (Format "00-0")/ APPOINTMENT
(Y/ N)
From To INCREMENT
08/15/2019 TO DATE SENIOR INSPECTOR (FIRE) BUREAU OF FIRE PROTECTION ₱ 56,582.00 23 PERMANENT Y
01/01/2019 08/14/2019 INSPECTOR (FIRE) BUREAU OF FIRE PROTECTION ₱ 49,528.00 22 PERMANENT Y
08/17/2012 11/12/2015 SENIOR FIRE OFFICER 4 BUREAU OF FIRE PROTECTION ₱ 27,425.00 19 PERMANENT Y
03/04/2003 12/18/2003 FIRE OFFICER 3 BUREAU OF FIRE PROTECTION ₱ 6,121.00 14 PERMANENT Y

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
N/A N/A N/A N/A N/A

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
FIRE NATIONAL TRAINING INSTITUTE
FIRE OFFICER ADVANCE COURSE 05/10/2021 08/31/2021 480.0 SUPERVISORY
CALAMBA, LAGUNA
FIRE OFFICER BASIC COURSE 07/05/2018 08/17/2018 480.0 SUPERVISORY
CALAMBA, LAGUNA
FIRE OFFICER CANDIDATE COURSE 02/27/2015 02/09/2015 960.0 SUPERVISORY
CALAMBA, LAGUNA
FIRE PROTECTION SUPERVISORY COURSE 10/01/2005 10/03/2005 320.0 SUPERVISORY
CALAMBA, LAGUNA
FIRE ARSON INVESTIGATION AND INSPECTION COURSE 10/01/2002 10/03/2002 480.0 TECHNICAL
CALAMBA, LAGUNA
PHILIPPINE NATIONAL POLICE TRAINING
PUBLIC SAFETY BASIC RECRUIT COURSE 01/04/1995 01/07/1995 552.0 TECHNICAL
CENTER REGION 9
VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)
FREE AND ACCEPTED MASON OF THE

DRIVIING MEDALYA NG PAGTULONG SA NASALANTA - 2
PHILIPPINES
BASKETBALL MEDALYA NG PAPURI - 4 FRATERNAL ORDERS OF EAGLES
COOKING

34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau 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? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:
35. a. Have you ever been found guilty of any administrative offense? YES NO
b. Have you been criminally charged before any court? YES NO

Date Filed:
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by YES NO
any court or tribunal? If YES, give details:
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, retirement, YES NO
dropped from the rolls, dismissal, termination, end of term, finished contract or phased out (abolition) in If YES, give details:
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 YES NO
Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country? YES 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? YES NO
If YES, please specify:
b. Are you a person with disability? YES NO
If YES, please specify ID No:
c. Are you a solo parent? YES NO
If YES, please specify ID No:
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
DGEN LINDY C LAUZON (RET) CAGAYAN DE ORO CITY 09778552772 4.5 cm. X 3.5 cm
(passport size)
SSUPT RICHIE E FABRE CAGAYAN DE ORO CITY 09178969622
Computer generated
or photocopied picture
CINSP CRISTINO T BANAC (RET) CAGAYAN DE ORO CITY 09276968978 is not acceptable
42. 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/authorized representative to verify/validate the contents stated herein. I
agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
administrative/criminal case/s against me.
Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: BUREAU OF FIRE PROTECTION
ID/License/Passport No.: O94007 Signature (Sign inside the box)

May 24, 2022 FEBRUARY 28, 2024
Date/Place of Issuance:
CAGAYAN DE ORO CITY Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this 28th day of February 2024 , affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath

1. POSITION TITLE (as approved by authorized agency)
Republic of the Philippines with parenthetical title
POSITION DESCRIPTION FORM
DBM-CSC Form No. 1
(Revised Version No. 1 , s. 2017)
CHIEF INSPECTOR (FIRE)
2. ITEM NUMBER 3. SALARY GRADE
U-05-0041 SG-24
4. FOR LOCAL GOVERNMENT POSITION, ENUMERATE GOVERNMENTAL UNIT AND CLASS
Province 1st Class 5th Class

City 2nd Class 6th Class
Municipality 3rd Class Special
4th Class
5. DEPARTMENT, CORPORATION OR AGENCY/ 6. BUREAU OR OFFICE

LOCAL GOVERNMENT
DEPARTMENT OF THE INTERIOR AND LOCAL

BUREAU OF FIRE PROTECTION
GOVERNMENT
7. DEPARTMENT / BRANCH / DIVISION 8. WORKSTATION / PLACE OF WORK
OFFICE OF THE CITY FIRE MARSHAL GINGOOG CITY FIRE STATION
9. PRESENT APPROP ACT 10. PREVIOUS APPROP ACT 11. SALARY AUTHORIZED 12. OTHER COMPENSATION
P 62, 555.00/mo., PERA, Hazard Pay, Quarter Allowance,
N/A Provisional Allowance, Laundry Allowance, Mid/ End Year
Bonus, PBB, PIB
13. POSITION TITLE OF IMMEDIATE SUPERVISOR 14. POSITION TITLE OF NEXT HIGHER SUPERVISOR
PROVINCIAL FIRE MARSHAL REGIONAL CHIEF OF STAFF
15. POSITION TITLE, AND ITEM OF THOSE DIRECTLY SUPERVISED

(if more than seven (7) list only by their item numbers and titles)
POSITION TITLE ITEM NUMBER
OIC, Operation Section U-10-1815
OIC, Admin Section U-10-0614
16. MACHINE, EQUIPMENT, TOOLS, ETC., USED REGULARLY IN PERFORMANCE OF WORK

Fire Truck, Firefighting Equipment, Computer, Printer, Office Supplies, Telephone, Internet, Digital Recorder
17. CONTACTS / CLIENTS / STAKEHOLDERS
17a. Internal Occasional Frequent 17b. External Occasional Frequent
Executive / Managerial General Public
Supervisors Other Agencies
Non-Supervisors Others (Please Specify):
Staff
18. WORKING CONDITION
Office Work Other/s (Please Specify)
Field Work
19. BRIEF DESCRIPTION OF THE GENERAL FUNCTION OF THE UNIT OR SECTION
Performs the duties and responsibilities of Municipal Fire Marshal and has command and control in the over-all functions of the
Fire Station
Page 1 of 2
20. BRIEF DESCRIPTION OF THE GENERAL FUNCTION OF THE POSITION (Job Summary)
1.Responsible for the implementation of various programs and projects under area of jurisdiction;
2. Represents the Station in various meetings, conferences and gatherings where the presence of Municipal Fire Marshal is necessary;
3. Responds to fire incidents in area of jurisdiction;
4. Conducts Fire Investigation of all fire incidents in the AOR and submit final investigation report to PFD;
5. Recommends issuance of Mission Orders for periodic fire safety inspection in the AOR;
6. Issues the Fire Safety Inspection Certificate (FSIC) upon the recommendation of the Chief, Fire Safety Enforcement Section (FSES); and
7. Performs other tasks that the Provincial Fire Director may assign.
21. QUALIFICATION STANDARDS
21a. Education 21b. Experience 21c. Training 21d. Eligibility
2nd year Bachelor of

Fire Officers Advance Course
Laws/24 units of Masters 3 years as Fire Senior Inspector Second (2nd) Level Eligibility
(FOAC) or its equivalent
Degree
21e. Core Competencies Competency Level

1. Decision Making Advanced
2. Work Standard Advanced
3. Managing Advanced
4. Integrity Advanced
5. Adaptability/Flexibility Advanced
6. Communication Advanced
21f. Leadership Competencies Competency Level
Building collaborative and inclusive working relationships Advanced
Managing Performance and Coaching for Resluts Advanced
Leading Change Advanced
Thinking Strategically and creatively Advanced
Creating and nurturing a high performing organization Advanced
22. STATEMENT OF DUTIES AND RESPONSIBILITIES (Technical Competencies) Competency Level
20% 1. Implements various programs and projects within area of jurisdiction; Advanced
2. Represents the Station in various meetings, conferences and

20% Advanced
gatherings where the presence of Municipal Fire Marshal is necessary;
15% 3. Responds to fire incidents in area of jurisdiction; Advanced

4. Conducts Fire Investigation of all fire incidents in AOR and submit
15% Advanced
final investigation report to PFD;
5. Recommends issuance of Mission Orders for periodic fire safety
10% Advanced
inspection in AOR;
6. Shall issue the Fire Safety Inspection Certificate (FSIC) upon the
10% Advanced
recommendation of the Chief, Fire Safety Enforcement Section (FSES);
10% 7. Performs other tasks that the Provincial Fire Director may assign. Advanced
23. ACKNOWLEDGMENT AND ACCEPTANCE:
I have received a copy of this position description. It has been discussed with me and I have freely chosen to comply with
the performance and behavior/conduct expectations contained herein.
CINSP RANDY N OBSIOMA / 02 MAY 2024 SUPT WILFREDO A DAVID / 02 MAY 2024
Employee's Name, Date and Signature Supervisor's Name, Date and Signature
Page 2 of 2
Attachment to CS Form No. 212
WORK EXPERIENCE SHEET

Instructions: 1. Include only the work experiences relevant to the position being applied to.
2. The duration should include start and finish dates, if known, month in abbreviated form,
if known, and year in full. For the current position, use the word Present, e.g., 1998-
Present. Work experience should be listed from most recent first.
• Duration: July 05, 2022 - Present

• Position: Senior Inspector/Acting City Fire Marshal
• Name of Office/Unit: Gingoog City Fire Station, Misamis Oriental, BFP Region 10
• Immediate Supervisor: SUPT WILFREDO A DAVID
• Name of Agency/Organization and Location: Bureau of Fire Protection, Region 10
• List of Accomplishments and Contributions (if any)
oExemplary efforts, devotion, and loyalty to service as BFP personnel, this region.
oRecipient of a Brand-New Ambulance from the BFP National Headquarters.
oSuccessfully defended the increased of BFP Gingoog annual budget from the city government for
2023.
o Conducted the first Fire Road Show of Gingoog City as one of the highlights in the celebration of
Fire Prevention Month.
• Summary of Actual Duties
o Performs the duties and responsibilities of Acting City Fire Marshal in AOR & Shall have the
command and control of fire station.
o Administer the General Inspection to all types of building occupancies, issues Inspection Orders to
all inspection activities and issues FSIC to compliant establishment and NOD or NTC and penalties
or administrative fines to non-compliant upon recommendation of C, FSES and perform other task
given by the PFD.
o Respond to all fire incidents in the area of jurisdiction, acts as ground commander during fire
operation, submit all fire investigation reports to the OPFD as well to the higher
officers/headquarters.
o Observed and approved/agreed running card system in terms of augmentation of force in fire
responses outside AOR.
o Implement various programs and projects within AOR and attend meetings, conferences &
gatherings representing the fire station where the presence of the Fire Marshal is necessary.
• Duration: September 13, 2021 - July 04, 2022

• Position: Senior Inspector/ Acting City Fire Marshal
• Name of Office/Unit: El Salvador City Fire Station, Misamis Oriental, BFP Region 10
• Immediate Supervisor: CINSP WILFREDO A DAVID
o Noteworthy display of excellence, competence and discipline in accomplishing the Bureau of Fire
Protection's (BFP) Task Force Implementation during the May 09, 2022 Elections.
o Prompt response and humanitarian assistance by donating relief goods extended to the people in
Siargao, Socorro and Dinagat Islands and construction materials extended to BFP Caraga
personnel who were severely affected by the devastation brought by typhoon "Odette" which
significantly contributed in alleviating the catastrophic effects in the lives of the people.
o Performs the duties and responsibilities of Acting City Marshal in AOR & Shall have the command
and control of fire station.
given by the PFD.
• Duration: August 27, 2019 - May 04, 2021

• Position: Senior Inspector/Municipal Fire Marshal
• Name of Office/Unit: Alubijid Fire Station, Misamis Oriental, BFP Region 10
• Immediate Supervisor: SUPT GREGORIO S ELBAMBO
o Laudable efforts, and prompt response of vehicular accident last 10 January 2021 at the National
Highway Brgy. Lanao, Alubijid, Misamis Oriental.
o Exemplary performance rendered as frontliners during the State of Public Health Emergency due to
Covid-19 Pandemic.
o Performs the duties and responsibilities of Municipal Fire Marshal in AOR & Shall have the
given by the PFD.
• Duration: August 15, 2019 - August 26, 2019

• Position: Senior Inspector/Municipal Fire Marshal
• Name of Office/Unit: PIE-MO Fire Station, Misamis Oriental, BFP Region 10
• Immediate Supervisor:
• List of Accomplishments and Contribution (If any)
o Performs the duties and responsibilities of Municipal Fire Marshal in AOR & Shall have the
given by the PFD.
FSINSP RANDY N OBSIOMA

(Signature over Printed Name
of Employee/Applicant)
Date: _28 February 2024

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CS Form No.

PERSONAL DATA SHEET

MIDDLE NAME NACALABAN

7. HEIGHT (m) 1.73m CAGAYAN DE ORO CITY MISAMIS ORIENTAL

9. BLOOD TYPE AB 18. PERMANENT ADDRESS BLOCK 41, LOT 14 STO.NIÑO

10. GSIS ID NO. 2003548296 KISANLU SUBDIVISION IPONAN

11. PAG-IBIG ID NO. 1080-0237-6730 CAGAYAN DE ORO CITY MISAMIS ORIENTAL

12. PHILHEALTH NO. 19-000516189-8 ZIP CODE 9000

13. SSS NO. N/A 19. TELEPHONE NO. N/A

14. TIN NO. 177-273-947 20. MOBILE NO. 09271334782

FIRST NAME SHEILA MARIE

MIDDLE NAME ONGKIATCO

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME OBSIOMA

MIDDLE NAME JABLA

25. MOTHER'S MAIDEN NAME

FIRST NAME EVA

MIDDLE NAME SABELLINA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

XAVIER UNIVERSITY BACHELOR OF SCIENCE IN CUSTOMS

SIGNATURE DATE FEBRUARY 28, 2024

CS FORM 212 (Revised 2017), Page 1 of 4

(Continue on separate sheet if necessary)

01/01/2019 08/14/2019 INSPECTOR (FIRE) BUREAU OF FIRE PROTECTION ₱ 49,528.00 22 PERMANENT Y

01/01/2018 12/31/2018 INSPECTOR (FIRE) BUREAU OF FIRE PROTECTION ₱ 43,685.00 22 PERMANENT Y

11/13/2015 12/31/2017 INSPECTOR (FIRE) BUREAU OF FIRE PROTECTION ₱ 32,341.00 22 PERMANENT Y

03/04/2003 12/18/2003 FIRE OFFICER 3 BUREAU OF FIRE PROTECTION ₱ 6,121.00 14 PERMANENT Y

01/01/2000 03/03/2002 FIRE OFFICER 2 BUREAU OF FIRE PROTECTION ₱ 5,300.00 12 PERMANENT Y

06/30/1999 12/31/1999 FIRE OFFICER 2 BUREAU OF FIRE PROTECTION ₱ 5,000.00 12 PERMANENT Y

01/01/1997 06/29/1999 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION ₱ 4,600.00 10 PERMANENT Y

01/01/1996 12/31/1996 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION ₱ 3,800.00 10 PERMANENT Y

01/01/1995 12/31/1995 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION ₱ 2,800.00 10 PERMANENT Y

11/18/1994 12/31/1994 FIRE OFFICER 1 BUREAU OF FIRE PROTECTION ₱ 1,800.00 10 PERMANENT Y

(Continue on separate sheet if necessary)

SIGNATURE DATE FEBRUARY 28, 2024

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

(Continue on separate sheet if necessary)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

FREE AND ACCEPTED MASON OF THE

(Continue on separate sheet if necessary)

SIGNATURE DATE FEBRUARY 28, 2024

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

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

NAME ADDRESS TEL. NO.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

ID/License/Passport No.: O94007 Signature (Sign inside the box)

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4

2. ITEM NUMBER 3. SALARY GRADE

4. FOR LOCAL GOVERNMENT POSITION, ENUMERATE GOVERNMENTAL UNIT AND CLASS

Province 1st Class 5th Class

5. DEPARTMENT, CORPORATION OR AGENCY/ 6. BUREAU OR OFFICE

DEPARTMENT OF THE INTERIOR AND LOCAL

7. DEPARTMENT / BRANCH / DIVISION 8. WORKSTATION / PLACE OF WORK

OFFICE OF THE CITY FIRE MARSHAL GINGOOG CITY FIRE STATION

PROVINCIAL FIRE MARSHAL REGIONAL CHIEF OF STAFF

15. POSITION TITLE, AND ITEM OF THOSE DIRECTLY SUPERVISED

16. MACHINE, EQUIPMENT, TOOLS, ETC., USED REGULARLY IN PERFORMANCE OF WORK

19. BRIEF DESCRIPTION OF THE GENERAL FUNCTION OF THE UNIT OR SECTION

3. Responds to fire incidents in area of jurisdiction;