CSC FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with and use separate sheets if necessary
1. CS
ID No.
(to be filled up by CSC)
I. PERSONAL INFORMATION
2. S!"#M$ N I D U A
%&!S' "#M$ M A Y
M&(()$ "#M$ Z A U S A
*. "#M$ $+'$"S&," (e.g.
-r.. Sr./
0. (#'$ ,% 1&!'2 (334dd4yyyy/ 05/01/1991 56. !$S&($"'&#) #((!$SS
BALACTASAN, MADALAG, AKLAN
7. P)#C$ ,% 1&!'2 MADALAG, AKLAN
6. S$+

Male Female

8&P C,($
59. '$)$P2,"$ ",.
9. C&:&) S'#'S
Single Widowed
Married Separated
Annulled Oters! spe"i#$
%%%%%%%%%%%%%%%%
5603
N/A
5;. P$!M#"$"' #((!$SS
BALACTASAN, MADALAG, AKLAN
;. C&'&8$"S2&P FILIPINO
<. 2$&=2' (3/ 1.5 !
5>. ?$&=2' (kg/ 50 "# 8&P C,($ 5603
55. 1),,( '@P$ $O% 5<. '$)$P2,"$ ",. N/A
52. =S&S P,)&C@ ",. A&&'()* 2>. $AM#&) #((!$SS (if any/ !+,-(*.+/,+011.21!
5*. P#=A&1&= ",. N/A 25. C$))P2,"$ ",. (if any/ 09363463955
50. P2&)2$#)'2 ",. A&&'()* 22. #=$"C@ $MP),@$$ ",. N/A
57. SSS ",. N/A 2*. '&" 339 60596 1356 000
II. FAMILY BACKGROUND
20. SP,S$BS S!"#M$ N/A
27. "#M$ ,% C2&)( (?rite full na3e
and list all/
(#'$ ,% 1&!'2 (334dd4yyyy/
%&!S' "#M$ N/A N/A N/A
M&(()$ "#M$ N/A
,CCP#'&," N/A
$MP),@$!41S. "#M$ N/A
1S&"$SS #((!$SS N/A
'$)$P2,"$ ",. N/A
(Continue on separate sheet if necessary)
26. %#'2$!BS S!"#M$ NIDUA
%&!S' "#M$ 7ERRY
M&(()$ "#M$ SAL8ADOR
29. M,'2$!BS M#&($" "#M$
S!"#M$ ZAUSA
%&!S' "#M$ HERMINIGILDA 9D)2)+:)*;
M&(()$ "#M$ PADALHIN (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
2;.
)$:$)
"a3e of School
(?rite in full/
($=!$$4C,!S$
(?rite in full/
@$#!
=!#(#'$( (if
graduated/
2ighest
=rade4 nits
$arned (if
not
graduated/
&"C)S&:$ (#'$S
,% #''$"(#"C$ #C#($M&C
2,",!S
!$C$&:$( F<1! T1
$)$M$"'#!@
MADALAG
ELEMENTARY SCHO0L
003 1994 003 =ITH HONORS
S$C,"(#!@
MADALAG NATIONAL
HIGH SCHOOL
004 003 004
:,C#'&,"#)4
'!#($
C,!S$S
N/A N/A N/A N/A N/A N/A N/A
C,))$=$
AKLAN CATHOLIC
COLLEGE
BACHELOR OF
SECONDARY
EDUCATION
011 004 011
=!#(#'$
S'(&$S
N/A N/A N/A N/A N/A N/A N/A
(Continue on separate sheet if necessary)
IV. CAREER SERVICED ELIGIBILITY
29. CARER SERVICE/ RS 1080
( BOARD/ BAR)
UNDER SPECIAL LAWS/ CES/ CSEE
RATIN
G
Date o
E!a"#$at#o$
Co$e%"e$t
P&a'e o
E!a"#$at#o$
Co$e%"e$t
LICENSE (# a((&#'a)&e)
N*")e% Date o Re&ea+e
LICENSURE E>AMINATION FOR
TEACHERS
44.00
SEPTEMBER
30, 01
ILOILO CITY 1140396 AUGUST 13, 013
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include !"#$%e e&l'(&en%. S%$!% )!'& ('u! cu!!en% *'!+,
*>.
&"C)S&:$ (#'$S
(334dd4yyyy/
P,S&'&,"4'&')$
(?rite in full/
($P#!'M$"'4#=$"C@4,%%&C$4
C,MP#"@
(?rite in full/
M,"'2)@
S#)#!@
S#)#!@
=!#($ C
S'$P
&"C!$M$"'
(%or3at >>A
>/
S'#'S ,%
#PP,&"'M$"'
=,:B'
S$!:&C$
(@es4"o/
FROM TO
05/16/13 PRESENT
TEACHER6 I
MUNICIPAL
SCHOOL BOARD
ALAMINOS ELEMENTARY
SCHOOL
P51.00 CONTRACTUAL YES
05/10/1 05/16/1
RESER8ATION
OFFICER
SOUTH=EST TOURS
BORACAY INC.
P9,456.00 CASUAL NO
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(Continue on separate sheet if necessary)
CS ,OR- 212 (Re.#+e/ 2000)1 Pa2e 2 o 3
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC - NON.GOVERNMENT - PEOPLE - VOLUNTARY
ORGANI/ATION
*5.
&"C)S&:$ (#'$S
"M1$!
,%
2,!S

"#M$ C #((!$SS ,% ,!=#"&8#'&," (334dd4yyyy/ P,S&'&,"4"#'!$ ,% ?,!D
(?rite in full/ %ro3 'o
CFC6SINGLES FOR CHRIST AKLAN 09/01/1 PRESENT

MEMBER
MADALAG TEACHERS LEAGUE 01/06/13 PRESENT

MEMBER



(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS- STUDY- SC0OLARS0IP GRANTS (S%$!% )!'& %1e &'2% !ecen% %!$"n"n3,
*2.
'&')$ ,% S$M&"#!4 C,"%$!$"C$4
?,!DS2,P4S2,!' C,!S$S
(?rite in full/
&"C)S&:$ (#'$S
(334dd4yyyy/
"M1$!
,%
2,!S
C,"(C'$(4SP,"S,!$( 1@
(?rite in full/
F<1! T1
BSP BASIC TRAINING COURSE 04/5/13 04/4/13 30<:
BOY SCOUTS OF THE PHILIPPINES
AKLAN COUNCIL
BSP SUMMER CAMP TRAINIG 03/19/13 03/1/13 30<:
BOY SCOUTS OF THE PHILIPPINES
AKLAN COUNCIL
BSP NATIONAL RO8ER MOOT 11/6/13 1/0/13 350<:
BOY SCOUTS OF THE PHILIPPINES
DISTRICT MID6YEAR ASSESSMENT
AND IN6SER8ICE TRAINING
10/9/13 10/31/13 30<:
DEPARTMENT OF EDUCATION
DISTRICT SEMINAR ON CHILD6
CENTERED LEANIN
06/5/13 06/30/13 30<:
DEPARTMENT OF EDUCATION
011 ANNUAL STUDENTS CONGRES
03/05/11 03/06/11 16 0<:
PHILIPPINE ASSOCIATION FOR TEACHERS
COOL MEDIA? EMPO=ERING
CAMPUS 7OURNALISM TO=ARDS
PUBLIC IN8OL8EMENT
04/5/10 04/30/10 16 0<:
AKLAN CATHOLIC COLLEGE 9SPAM;
8OTER@S EDUCATION AND ELECTION
AUTOMATION
03/01/10 03/01/10 5 0<: CATHOLIC EDUCATION ASSSOCIATION OF
THE PHILIPPINES
COOL MEDIA? NE=S =RITING TO
STIMULATE
0/06/10 0/04/10 160<:
AKLAN CATHOLIC COLLEGE THIRD YEAR6
7OURNALISM CLASS
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
(Continue on separate sheet if necessary)
VIII. OT0ER INFORMATION
**. SP$C&#) SD&))S4 2,11&$S *0. ","A#C#($M&C (&S'&"C'&,"S4 !$C,="&'&,"
(?rite in full/
*7. M$M1$!S2&P &"
#SS,C&#'&,"4 ,!=#"&8#'&,"
(?rite in full/
DANCING
BOY SCOUT OF THE
PHILIPPINES
HOSTING
GIRL SCOUT OF THE
PHILIPPINES
COMPUTER LITERATE
(Continue on separate sheet if necessary)
CS ,OR- 212 (Re.#+e/ 2000)1 Pa2e 4 o 3
*6. #re you related by consanguinity or affinity to any of the followingE
a. ?ithin the third degree (for "ational =oFern3ent $3ployees/E
appointing authority. reco33ending authority. chief office4bureau4depart3ent or
person who has i33ediate superFision oFer you in the ,ffice. 1ureau or
(epart3ent where you will be appointedG
b. ?ithin the fourth degree (for )ocal =oFern3ent $3ployees/E
appointing authority or reco33ending authority where you will be appointedG
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
*9. a. 2aFe you eFer been for3ally chargedG

b. 2aFe you eFer been declared guilty of any ad3inistratiFe offenseG
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
*;. 2aFe you eFer been conFicted of any cri3e or Fiolation of any law. decree.
ordinance or regulations by any court or tribunalG
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
*<. 2aFe you eFer been separated fro3 the serFice in any of the following 3odesE
resignation. retire3ent. dropped fro3 the rolls. dis3issal. ter3ination. end of ter3.
finished contract. #?,) or phased out. in the public or priFate sectorG
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
0>. 2aFe you eFer been candidate in a national or local election (except 1arangay
election/G
@$S ",
&f @$S. giFe detailsE
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
05. Pursuant toE (a/ &ndigenous PeopleBs #ct (!# ;*95/I (b/ Magna Carta for
(isabled Persons (!# 9299/I and (c/ Solo Parents ?elfare #ct of 2>>> (!#
;<92/J. please answer the following ite3sE

a. #re you a 3e3ber of any indigenous groupG

b. #re you differently ableG
c. #re you a solo parentG
@$S ",
&f @$S. please specify. HHHHHHHHHHHHHHHHHHHHH
@$S ",
&f @$S. please specifyE HHHHHHHHHHHHHHHHHHHHH

@$S ",
&f @$S. please specifyE HHHHHHHHHHHHHHHHHHHHH
&2' R(F(R()C(S (*erson not related +$ "onsanguit$ to appli"ant,appointee)
"#M$ #((!$SS '$) ",.
PHOTO
MR .MAR8IE I. NA8IDA
MADALAG ELEMENTARY SCHOOL
MADALAG, AKLAN
09104349596
MS. E8ELINA G. GAYO
AKLAN CATHOLIC COLLEGE
KALIBO, AKLAN
656315
MS. ANAMY GOMEZ
SOUTH=EST TOURS BORACAY INC.
KALIBO, AKLAN
6565100
33. & declare under the penalties of perKury that this Personal (ata Sheet has been acco3plished
in good faith. Ferified by 3e and to the best of 3y knowledge and belief is a true. correct and
co3plete state3ent pursuant to the proFisions of pertinent laws. rules and regulations of the
!epublic of the Philippines.
& also authoriLe the agency head or its authoriLed representatiFe to Ferify 4 Falidate the
contents stated herein. & trust that this infor3ation shall re3ain C,"%&($"'&#).

SIGNATURE
DATE ACCOMPLISHED
RIGHT THUMBMARK
ID picture taken within the last 6
months 3.5mm X 4.5mm
(passport size)
Computer generated or Xero cop!
o" picture is not accepta#le
134411
COMMUNITY TA> CERTIFICATE NO.
(Continue on separate sheet if necessary) 9CSC F1<! 1 9R)A(:)* 005;, Pa2e 3 o 3