2.

SURNAME
FIRST NAME
MIDDLE NAME
4.
LOT 17, BLOCK 4, NHA SUBDIVISION ALIMANAO,
5. PLACE OF BIRTH
PEABLANCA, CAGAYAN
6. SEX
17. TELEPHONE NO.
LOT 17, BLOCK 4, NHA SUBDIVISION ALIMANAO,
8. CITIZENSHIP
PEABLANCA, CAGAYAN
9. HEIGHT (m)
10. WEIGHT (kg)
11. BLOOD TYPE
12. GSIS ID NO.
13. PAG-IBIG ID NO.
14. PHILHEALTH NO.
15. SSS NO.
24. SPOUSE'S SURNAME
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
26.
27.
From To
1983 1977 1983
1987 1983 1987
2012
GRADUATE STUDIES
UNIVERSITY OF CAGAYAN
VALLEY
MBA 12 UNITS 2012
COLLEGE
28.
D | A | Y | R | I | T | | | | | | | | | | | | | | | | | | | | | | |
"O"
YEAR
GRADUATED
(if graduated)
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
HOOL
SECONDARY
VOCATIONAL /
TRADE COURSE
N/A
GRADUATE STUDIES
GRADUATED
15 UNITS
CAGAYAN COLLEGES
TUGUEGARAO
Print legibly. Mark appropriate boxes q with "P" and use separate sheet if necessary.
I. PERSONAL INFORMATION
7.
ZIP CODE
18. PERMANENT ADDRESS
DATE OF BIRTH (mm/dd/yyyy)
TUGUEGARAO, CAGAYAN
16. RESIDENTIAL ADDRESS
3. NAME EXTENSION (e.g. Jr., Sr.)
CIVIL STATUS
ST. LOUIS COLLEGE OF
TUGUEGARAO
INCLUSIVE DATES OF
ATTENDANCE
GRADUATED
PERSONAL DATA SHEET
CS FORM 212 (Revised 2005)
1. CS ID No. (to be filled up by CSC)
73 KLS. 3507
/ /
II. FAMILY BACKGROUND
19. TELEPHONE NO.
/ /
DATE OF BIRTH (mm/dd/yyyy)
158-496-742
21. CELLPHONE NO. (if any)
06-000015414-0
01-0945738-9
22. AGENCY EMPLOYEE NO.
FIRST NAME
LEVEL
MOTHER'S MAIDEN NAME
SURNAME
MIDDLE NAME
DAYRIT
III. EDUCATIONAL BACKGROUND
/ /
/ /
/ /
KRISTELLE MIAH D. VERGARA
DEGREE COURSE
(Write in full)
NAME OF SCHOOL
(Write in full)
ST. LOUIS COLLEGE OF
TUGUEGARAO
TUGUEGARAO WEST CENTRAL
FIRST NAME
PILAR
CENTRO ALCALA, CAGAYAN
CONCHITO, SR.
V |E |R | G | A |R |A | | | | | | | | | | | | | | | |
V | I | T | A | | | | | | | | | | | | | | | | | | | |
3507
5'3
ZIP CODE
FILIPINO
9/3/1970
JAN EIMEE D. VERGARA
/ /
/ /
N/A
MIDDLE NAME
DANGUILAN
CORTES
TUDDAO
(Continue on separate sheet if necessary)
FATHER'S SURNAME
EMERSON
CERIA
GOVERNMENT EMPLOYEE
23. TIN
PAULA EVIA D. VERGARA
(Continue on separate sheet if necessary)
FEB. 07, 1995
/ /
MUNICIPAL GOVERNMENT OF ALCALA
/ /
JAN. 31, 2007
25. NAME OF CHILD (Write full name and list all)
NOV. 16, 1996
20. E-MAIL ADDRESS (if any)
VERGARA
1991 1987 1991
BSC-
MANAGEMENT
WITH 18 UNITS
ACCOUNTING
GRADUATED
1999 1998 MPA

Male Female


q



Single







Married



q



Annulled



q



Widowed



q



Separated



q



Others, specify ___________



LOT 17, BLOCK 4, NHA SUBDIVISION ALIMANAO,
LOT 17, BLOCK 4, NHA SUBDIVISION ALIMANAO,
Page 1 of 4
I. PERSONAL INFORMATION
SCHOLARSHIP/ ACADEMIC
HONORS RECEIVED
PERSONAL DATA SHEET
CS FORM 212 (Revised 2005)
(to be filled up by CSC)
3507
/ /
II. FAMILY BACKGROUND
/ /
DATE OF BIRTH (mm/dd/yyyy)
158-496-742
III. EDUCATIONAL BACKGROUND
/ /
/ /
/ /
V |E |R | G | A |R |A | | | | | | | | | | | | | | | |
V | I | T | A | | | | | | | | | | | | | | | | | | | |
3507
/ /
/ /
(Continue on separate sheet if necessary)
FEB. 07, 1995
/ /
/ /
JAN. 31, 2007
NOV. 16, 1996
29.
NUMBER
DATE OF
RELEASE
80.26%
30.
To
06/30/2014 P1,131.22/d 11 CASUAL YES
12/31/2013 P1,131.22/d 11 CASUAL YES
06/30/2013 P1,131.22/d 11 CASUAL YES
12/31/2012 P1,031.22/d 11 CASUAL YES
06/30/2012 P1,031.22/d 11 CASUAL YES
12/31/2011 P1,031.22/d 11 CASUAL YES
06/30/2011 P931.36/d 11 CASUAL YES
12/30/2010 P831.45/d 11 CASUAL YES
06/30/2010 P831.45/d 11 CASUAL YES
12/31/2009 P731.50/d 11 CASUAL YES
06/30/2009 P579.45/d 9 CASUAL YES
12/31/2008 P447.63/d 7 CASUAL YES
09/30/2008 P387.13/d 5 CASUAL YES
12/31/2008 P352.13/d 5 CASUAL YES
12/31/2005 P200/d CASUAL YES
07/14/1998 P6,000/mo. PERMANENT NO
CS FORM 212 (Revised 2005), Page 2 of 4
PROVINCIAL TREASURER'S OFFICE
PROVINCIAL TREASURER'S OFFICE
01/01/2014
LOCAL TREASURY OPERATIONS
OFFICER II
PROVINCIAL TREASURER'S OFFICE
PROVINCIAL TREASURER'S OFFICE
PROVINCIAL TOURISM OFFICE
(Continue on separate sheet if necessary)
CLERK I
REVENUE COLLECTION CLERK I
01/01/2008
PROVINCIAL TREASURER'S OFFICE
TUG. NORTH CENTRAL SCHOOL
PROVINCIAL TREASURER'S OFFICE
STATUS OF
APPOINTMENT
GOV'T
SERVICE
(Yes / No)
SALARY
GRADE & STEP
INCREMENT
(Format "00-0")
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
REVENUE COLLECTION CLERK I
PROVINCIAL TREASURER'S OFFICE
EXECUTIVE SECRETARY CARSUMCO,PIAT, CAGAYAN
07/28/1991 CS PROFESSIONAL LEVEL
PROVINCIAL TREASURER'S OFFICE
LOCAL TREASURY OPERATIONS
OFFICER II
MONTHLY
SALARY
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
POSITION TITLE
(Write in full)
08/01/2007
07/15/1998
08/16/1992
09/01/2008 REVENUE COLLECTION CLERK II
LOCAL TREASURY OPERATIONS
OFFICER II
01/01/2011
01/01/2009
07/01/2010
LOCAL TREASURY OPERATIONS
OFFICER I
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
UNDER SPECIAL LAWS/ CES/ CSEE
DATE OF
EXAMINATION /
CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
LICENSE (if applicable)
RATING
IV. CIVIL SERVICE ELIGIBILITY
LOCAL TREASURY OPERATIONS
OFFICER II
07/01/2009
01/01/2010
LOCAL TREASURY OPERATIONS
OFFICER II
PROVINCIAL TREASURER'S OFFICE
INCLUSIVE DATES
(mm/dd/yyyy)
From
PROVINCIAL TREASURER'S OFFICE
07/01/2011
LOCAL TREASURY OPERATIONS
OFFICER II
01/01/2012
LOCAL TREASURY OPERATIONS
OFFICER II
PROVINCIAL TREASURER'S OFFICE
07/01/2012
LOCAL TREASURY OPERATIONS
OFFICER II
PROVINCIAL TREASURER'S OFFICE
01/01/2013
LOCAL TREASURY OPERATIONS
OFFICER II
PROVINCIAL TREASURER'S OFFICE
07/01/2013
LOCAL TREASURY OPERATIONS
OFFICER II
PROVINCIAL TREASURER'S OFFICE
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
From To
10/24/2012 10/27/2012 32
12/16/2011 12/16/2011 8
10/12/2011 10/14/2011 24
10/13/2010 10/15/2010 24
08/29/2008 08/29/2008 8
FRONTLINE OFFICE OPERATIONS & HOUSEKEEPING
07/23/2002 07/25/2002 24
07/10/2001 07/11/2001 16
VALUES ORIENTATION WORKSHOP
01/26/1999 01/28/1999 24
05/18/1999 05/21/1999 32
33. SPECIAL SKILLS / HOBBIES: 34. 35.
31.
VII. TRAINING PROGRAMS (Start from the most recent training.)
ASSOCIATION OF GOVERNMENT ACCOUNTANTS OF THE PHILS.
ANNUAL CONVENTION CUM SEMINAR
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
ASSOCIATION OF GOVERNMENT
ACCOUNTANTS OF THE PHILS.
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)
CIVIL SERVICE COMMSSION
FRONTLINE SERVICES MANAGEMENT TRAINING
(Continue on separate sheet if necessary)
Provincial Treasurer's Office
ASSOCIATION OF GOVERNMENT
INTERNAL AUDITORS, INC.
CIVIL SERVICE COMMISSION
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
(Write in full)
COMPUTER LITERATE
CLERICAL WORKS
CS FORM 212 (Revised 2005), Page 3 of 4
(Continue on separate sheet if necessary)
CASH/REVENUE AUDITING
CONDUCTED/ SPONSORED BY
(Write in full)
ASSOCIATION OF GOVERNMENT INTERNAL AUDITORS,INC. ANNUAL
CONVENTION CUM SEMINAR (INTERNAL AUDITING)
Refresher Course for Real Property Tax Collection and Target
Setting
NAME & ADDRESS OF ORGANIZATION
(Write in full)
INCLUSIVE DATES
(mm/dd/yyyy)
NUMBER OF
HOURS
POSITION / NATURE OF WORK
VIII. OTHER INFORMATION
TECHNICAL/REPORT WRITING and BASIC RECORDS MANAGEMENT
SEMINAR
INCLUSIVE DATES OF ATTENDANCE
(mm/dd/yyyy)
32.
NUMBER OF
HOURS
ASSOCIATION OF GOVERNMENT
INTERNAL AUDITORS, INC.
DEPARTMENT OF TOURISM
ASSOCIATION OF GOVERNMENT INTERNAL AUDITORS,INC. ANNUAL
CONVENTION CUM SEMINAR (INTERNAL AUDITING)
Provincial Government of Cagayan thru
Prov'l Planning and Development Office
DEPARTMENT OF TOURISM
ALAY SA BAYAN
PLANNING,ORGANIZING ,RECORDING
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (Start from the most recent training.)
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
ASSOCIATION OF GOVERNMENT
ACCOUNTANTS OF THE PHILS.
CIVIL SERVICE COMMSSION
(Continue on separate sheet if necessary)
Provincial Treasurer's Office
ASSOCIATION OF GOVERNMENT
INTERNAL AUDITORS, INC.
CIVIL SERVICE COMMISSION
CS FORM 212 (Revised 2005), Page 3 of 4
(Continue on separate sheet if necessary)
CONDUCTED/ SPONSORED BY
(Write in full)
POSITION / NATURE OF WORK
VIII. OTHER INFORMATION
ASSOCIATION OF GOVERNMENT
INTERNAL AUDITORS, INC.
DEPARTMENT OF TOURISM
Provincial Government of Cagayan thru
Prov'l Planning and Development Office
DEPARTMENT OF TOURISM
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
(Continue on separate sheet if necessary)
36.
a.
b.
37
38.
39.
40.
41.
a.
b.
c.
42.
NAME ADDRESS
ENGR. ROMEO VILLANUEVA,OPTNS. MANAGER CARSUMCO,PIAT,CAGAYAN
SALUD B. VITUG,STOO IV PROVINCIAL TOURISM OFFICE
EMILIA L. IRINGAN, PROVINCIAL TREASURER PROVINCIAL TREASURER'S OFFICE
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
ISSUED ON (mm/dd/yyyy) RIGHT THUMBMARK
If YES, give details:
________________________________
________________________________
If YES, please specify: ____________________
If YES, give details:
________________________________
________________________________
If YES, please specify: ____________________
If YES, please specify: ____________________
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?
SIGNATURE (Sign inside the box)
43.
CS FORM 212 (Revised 2005), Page 4 of 4
DATE ACCOMPLISHED
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.
REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.
846-7576
304-1969-6090
TEL. NO.
Are you related by consanguinity or affinity to any of the following :
Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
Within the third degree (for National Government Employees):
appointing authority, recommending 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?
a. Have you ever been formally charged?
b. Have you ever been guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
Are you a solo parent?
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
or phased out, in the public or private sector?
Have you ever been a candidate in a national or local election (except Barangay election)?
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:
Are you differently abled?
Are you a member of any indigenous group?
If YES, give details:
________________________________
________________________________
If YES, give details:
________________________________
________________________________
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO



ID picture taken within
the last 6 months
3.5 cm. X 4.5 cm
(passport size)


Computer generated
or xerox copy of picture
is not acceptable

YES NO