2.

SURNAME
FIRST NAME
MIDDLE NAME
4.
5. PLACE OF BIRTH
6. SEX
17. TELEPHONE NO.
8. CITIZENSHIP
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
2000 JUNE 1994 MARCH 2001 NONE
2004` JUNE 2001 APRIL 2004 NONE
2008 JUNE 2004 APRIL 3, 2008 NONE
Page 1 of 4
GRADUATE STUDIES
BACHELOR IN
ELEMENTARY
EDUCATION
MASTERAL
EDUCATION IN
MATHEMATICS
ELEMENTARY
SECONDARY
VOCATIONAL /
TRADE COURSE
27 UNITS MARIANO MARCOS STATE UNIVERSITY
MARIANO MARCOS STATE UNIVERSITY
I. PERSONAL INFORMATION
7.
COLLEGE OF TEACHER EDUCATION
GRADUATE SCHOOL
ZIP CODE
18. PERMANENT ADDRESS
II. FAMILY BACKGROUND
III. EDUCATIONAL BACKGROUND
COLLEGE
28.
A | G | C | A | O | I | L | I | | | | | | | | | | | | | | | | | | | | | | | |
911300000893
DATE OF BIRTH (mm/dd/yyyy)
(Continue on separate sheet if necessary)
10/03/1956
/ /
05/06/1966
/ /
SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED
PERSONAL DATA SHEET
CS FORM 212 (Revised 2005)
1. CS ID No. (to be filled up by CSC) Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary.
/ /
INCLUSIVE DATES OF ATTENDANCE
05/13/1987
0946-585-6832 21. CELLPHONE NO. (if any)
ZIP CODE
FILIPINO
19. TELEPHONE NO.
n/a
53 kgs.
"O"
2900
NAME OF SCHOOL
(Write in full)
ILOCOS NORTE NATIONAL HIGH SCHOOL
NAVOTAS ELEMENTARY SCHOOL
HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)
MOTHER'S MAIDEN NAME
SURNAME
FATHER'S SURNAME
FIRST NAME LILIBETH
FIRST NAME REMIGIO
MIDDLE NAME
FIESTA
F | I | E | S | T | A | | | | | | | | | | | | | | | | | | | | | | | | | |
R | E | M | E | L | Y | N | | | | | | | | | | | | | | | | | | | | | | | | |
2900
BRGY. 62-A NAVOTAS, LAOAG CITY
1.58m.
BRGY. 62-A NAVOTAS, LAOAG CITY LAOAG CITY
16. RESIDENTIAL ADDRESS
3. NAME EXTENSION (e.g. Jr., Sr.)
02004117479
(Continue on separate sheet if necessary)
05-000086592-0
22. AGENCY EMPLOYEE NO.
23. TIN 407-243-294
LEVEL
DEGREE COURSE
(Write in full)
YEAR
GRADUATED
(if graduated)
MIDDLE NAME AGCAOILI
CRISTOBAL
FIESTA
CIVIL STATUS
(Continue on separate sheet if necessary)
/ /
n/a
fiesta.remelyn@yahoo.com
/ /
25. NAME OF CHILD (Write full name and list all)
/ /
20. E-MAIL ADDRESS (if any)
/ /
DATE OF BIRTH (mm/dd/yyyy)
/ /
/ /
/ /
/ /
Annulled

Others, specify ___________





Single





Married







Widowed





Separated







Male Fem ale
29.
NUMBER
DATE OF
RELEASE
82.00% 1009092 01/26/2009
30.
To
PRESENT 18,549.00
GRADE II
STEP I
YES
02/15/2011 5,000.00 N/A TEACHER NO
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
CS FORM 212 (Revised 2005), Page 2 of 4
/ /
(Continue on separate sheet if necessary)
STATUS OF
APPOINTMENT
GOV'T SERVICE
(Yes / No)
SALARY GRADE
& STEP
INCREMENT
(Format "00-0")
/ /
LICENSURE EXAMINATION FOR TEACHERS 09/28/2008 BAGUIO CITY
MONTHLY
SALARY
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
/ /
/ /
/ /
/ /
/ /
DEPARTMENT OF EDUCATION
DIVISION OF LAOAG CITY
DEPARTMENT / AGENCY / OFFICE / COMPANY
(Write in full)
TEACHER I
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
POSITION TITLE
(Write in full)
INCLUSIVE DATES
(mm/dd/yyyy)
STARKIDZ TUTORIAL CENTER
From
08/24/2009
/ /
TEACHER II
03/16/2011
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
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
From To
09/29/2013 09/29/2013 24
11/17/2012 11/24/2012 24
10/25/2012 10/25/2013 8
12/26/2011 12/26/2011 8
09/10/2011 09/10/2011 16
07/21/2011 07/21/2011 8
05/17/2011 05/21/2011 54
05/02/2011 05/03/2011 16
12/12/2013 12/13/2013 16
33. SPECIAL SKILLS / HOBBIES: 34. 35.
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES
(Write in full)
CS FORM 212 (Revised 2005), Page 3 of 4
(Continue on separate sheet if necessary)
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
DIVISION TRANING ON ON REPUBLIC ACT 9184 AND ITS
IMPLEMENTING RULES AND REGULATIONS
DIVISION TRAINING WORKSHOP ON BASIC CHILDREN CHOIR
CONDUCTING FOR PUBLIC SCHOOL MSEPK TEACHER
NOT APPLICABLE
NUMBER OF
HOURS
REGIONAL TRAINING-WORKSHOP FOR SCHOOL PAPER
ADVISERS AND CAMPUS JOURNALIST
DIVISION TRAINING WORKSHOP ON INFORMATION AND
COMMUNICATION TECHNOLOGY (ICT)
DIVISION SEMINAR WORKSHOP FOR PUBLIC ELEMENTARY
SCHOOL TEACHER ON BASIC CONCEPTOF ENGLISH
LANGUAGE TEACHING AND TESTING: A REVIEW
DIVISION SEMINAR - WORKSHOP ON SIMPLIFIED
ACCOUNTING
SPG ADVISERS TRAINING
DISTRICT LEARNING CELL CEMINAR WORKSHOP ON TEST
CONSTRACTION
INDUCTION PROGRAM FOR THE BEGINNING TEACHER
DEPEd Laoag City
DEpEd Laoag City
MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
DISTRICT II, DepEd Laoag City
DEpEd Laoag City
DEpEd Laoag City
DEPEd Laoag City
31.
VII. TRAINING PROGRAMS (Start from the most recent training.)
DepEd Laoag City
BINALONAN, PANGASINAN
DepEd Regional
DIVISION OF LAOAG CITY
CONDUCTED/ SPONSORED BY
(Write in full)
INCLUSIVE DATES OF ATTENDANCE
(mm/dd/yyyy)
32.
(Continue on separate sheet if necessary)
NAME & ADDRESS OF ORGANIZATION
(Write in full)
INCLUSIVE DATES
(mm/dd/yyyy)
NUMBER OF
HOURS
POSITION / NATURE OF WORK
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
(Write in full)
36.
a.
b.
37
38.
39.
40.
41.
a.
b.
c.
42.
NAME ADDRESS
PHOTO
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
/ /
ISSUED ON (mm/dd/yyyy) RIGHT THUMBMARK
Are you related by consanguinity or affinity to any of the following :
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
Within the fourth degree (for Local Government Employees):
appointing authority or recommending authority where you will be appointed?
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?
Are you a member of any indigenous group?
Are you differently abled?
If YES, give details:
________________________________
________________________________
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?
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.
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.
If YES, give details:
_____________________________________
_____________________________________
_____________________________________
a. Have you ever been formally charged?
b. Have you ever been guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
If YES, give details:
________________________________
________________________________
Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?
If YES, please specify: ____________________
If YES, please specify: ____________________
If YES, give details:
________________________________
________________________________
Have you ever been a candidate in a national or local election (except Barangay election)?
If YES, give details:
________________________________
________________________________
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 a solo parent?
If YES, please specify: ____________________
TEL. NO.
REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)




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
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO