CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "

1. CS ID No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME
FIRST NAME

C | A| P | I |T | U | L | O |

| |

| | | | | | | | | | | | | | |

T | E | R | E | S | I |T | A |

| |

| | | | | | | | | | | | | | |

I|N |O |N |G |

MIDDLE NAME

| |

| |

| | | | |

CAPAS, TARLAC
Male

6. SEX
7. CIVIL STATUS

| | | 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS

12/31/1962

4. DATE OF BIRTH (mm/dd/yyyy)

5. PLACE OF BIRTH

BLK. 7, LOT 18, CRISTO REY, CAPAS, TARLAC

Fem ale

Single

Widowed

Married

Separated

Annulled

___________Others, specify18. PERMANENT ADDRESS

ZIP CODE

2315
09099891526

17. TELEPHONE NO.

8. CITIZENSHIP

FILIPINO

BLK. 7, LOT 18, CRISTO REY, CAPAS, TARLAC

9. HEIGHT (m)

1.64M

10. WEIGHT (kg)

68 Kg

11. BLOOD TYPE

"AB"

19. TELEPHONE NO.

09099891526

12. GSIS ID NO.

006005250037

20. E-MAIL ADDRESS (if any)

tsicapricorn31@yahoo.com

21. CELLPHONE NO. (if any)

09099891526

22. AGENCY EMPLOYEE NO.

4341771

23. TIN

208-133-364-000

ZIP CODE

13. PAG-IBIG ID NO.

14. PHILHEALTH NO.

07-000-081-367-0

15. SSS NO.

2315

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME

25. NAME OF CHILD (Write full name and list all)

CAPITULO

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAMEJOBALARMO

JAN JOSEF I. CAPITULO

01/21/1995

MIDDLE NA

CUIZON

JAMELLA I. CAPITULO

10 /08 / 1997

OCCUPATION

OFW

JARED KYLE I. CAPITULO

11/16/1999

EMPLOYER/BUS. NAME

SAUDI ELECTRIC COMPANY

JENIERO I. CAPITULO

BUSINESS ADDRESS

KSA

09 / 27 / 2006
/

(Continue on separate sheet if necessary)

INONG

FIRST NAME

GONZALO

MIDDLE NAME

PANTALEON

TELEPHONE NO.

26. FATHER'S SURNAME

27. MOTHER'S MAIDEN NAME

SURNAME

SORIANO

FIRST NAME

PILAR

MIDDLE NAME

AQUINO

(Continue on separate sheet if necessary)

YEAR
GRADUATED

III. EDUCATIONAL BACKGROUND

28.

NAME OF SCHOOL
LEVEL

(Write in

DEGREE COURSE
(Write in full)

full)

(if
graduated)

INCLUSIVE DATES OF
ATTENDANCE

HIGHEST GRADE/
LEVEL/
UNITS EARNED
(if not graduated)

From

To

ELEMENTARY

CAPAS WEST CENTRAL

ELEMENTARY

1979

GRADUATE

1969

1975

SECONDARY
VOCATIONAL /

DOMINICAN SCHOOL

HIGH SCHOOL

1979

GRADUATE

1975

1979

UNIVERSITY OF BAGUIO

BSEED

1983

GRADUATE

1979

1983

PAMPANGA AGRICULTURAL COLLEGE

Master in Professional
1999
Studies

GRADUATE

1997

1999

PAMPANGA AGRICULTURAL COLLEGE

Doctor of Education

Academic
Requirements

2008

2011

COLLEGE
TRADE
COURSE

GRADUATE STUDIES

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

(Continue on separate sheet if necessary)

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29.

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER

SPECIAL LAWS/ CES/ CSEE

LET

RATING

75.40%

DATE OF
EXAMINATION /
CONFERMENT

08/01/1997

LICENSE (if applicable)

PLACE OF EXAMINATION / CONFERMENT

TARLAC CITY

NUMBER

0324008

DATE OF
RELEASE

03-02-98

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
INCLUSIVE DATES
(mm/dd/yyyy)

30.

From

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

To

(Write in full)

GOV'T
SERVICE
MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT
(Yes /

No)

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

INCLUSIVE DATES
31. NAME & ADDRESS OF ORGANIZATION

NUMBER OF
HOURS

(mm/dd/yyyy)

(Write in full)
From

POSITION / NATURE OF WORK

To

(Continue on separate sheet if necessary)

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

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)
From

ORIENTATION / BRIEFING on the NATIONWIDE

OUT OF BATCH 7

ROLL

NUMBER OF
HOURS

(mm/dd/yyyy)

CONDUCTED/ SPONSORED BY
(Write in full)

To

08 / 24 /11

08 / 25 /11

16

DEPED/ICTU TECHNICAL SERVICES

NATIONAL SEMINAR on CONSTRUCTION & INTERPRETATION

12 / 28 /09

12 /30 /09

24

DEPED

SOUTHEAST ASIA MINISTRY of EDUCATION ORGANIZATION

TEACHERS' CAMP

10 / 06 /04

10 / 09 /04

32

SEAMEO-QEE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

33.

SPECIAL SKILLS / HOBBIES:

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

34.
(Write in full)

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)

TYPING
COMPUTER LITERATE

(Continue on separate sheet 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
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

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?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees):

appointing authority or recommending authority where you will be appointed?

37 a. Have you ever been formally charged?

YES

NO

If YES, give details:

________________________________
________________________________
YES

b. Have you ever been guilty of any administrative offense?

NO

If YES, give details:

________________________________
________________________________
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or

YES
NO
If YES, give details:
________________________________
________________________________

regulation by any court or tribunal?

39. Have you ever been separated from the service in any of the following modes: resignation,

YES

retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
phased out, in the public or private sector?

NO

If YES, give details:

________________________________
________________________________

40. Have you ever been a candidate in a national or local election (except Barangay election)?

YES

NO

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?

b.

Are you differently abled?

c.

Are you a solo parent?

YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________
YES
NO
If YES, please specify: ____________________

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

NAME

ADDRESS

TEL. NO.

MR. VICTOR O. SANTOS JR

O'DONNELL, CAPAS, TARLAC

9195699221

MR. ARTHUR GUERRERO

O'DONNELL, CAPAS, TARLAC

9219639919

KGD. MERLY T. VILLANUEVA

O'DONNELL, CAPAS, TARLAC

9213653708

43. 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.
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust
that this information shall remain confidential.

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

PHOTO

05167471
COMMUNITY TAX CERTIFICATE NO.

CAPAS, TARLAC
ISSUED AT

01/12/2012
ISSUED ON (mm/dd/yyyy)

SIGNATURE (Sign inside the box)

09/12/2012
DATE ACCOMPLISHED

RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4