CS Form 212 (Revised 2005) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

PERSONAL DATA SHEET

1
Print Legibly. Mark appropriate boxes "¨" with "ü" and use separate sheet if necessary CS ID No. to be filled up by CSC
I. PERSONAL INFORMATION
2 SURNAME R U B I

FIRST NAME G E N E L Y N

MIDDLE NAME M O N T E R O 3
NAME EXTENSION(e.g. Jr.,Sr.,)
4 DATE OF BIRTH (mm/dd/yyyy) 9/5/1989 16 RESIDENTIAL ADDRESS
5 PLACE OF BIRTH TAGO, SURIGAO DEL SUR Purok Citrus I, Barangay Purisima, Tago,
6 SEX
Surigao del Sur
Male Female
7 CIVIL STATUS Single Widowed ZIP CODE 8302

✘ Married Separated 17 TELEPHONE NO. n/a

Annulled Others, specify _______ 18 PERMANENT ADDRESS

8 CITIZENSHIP Purok Citrus I, Barangay Purisima,
FILPINO
Tago, Surigao del Sur
9 HEIGHT (m) 1.59
10 WEIGHT (Kg) 63kg ZIP CODE 8302
11 BLOOD TYPE O 19 TELEPHONE NO. n/a
12 GSIS ID NO. 20 E-MAIL ADDRESS (if any) genelynrubi@gmail.com
2004791062
13 PAG-IBIG ID NO. 21 CELLPHONE NO. (if any) 9300560777
18-251132562-6
14 PHILHEALTH NO. 22 AGENCY EMPLOYEE NO.
1211-57469247
15 SSS NO. 23 TIN 447-475-170-000
N/A
II. FAMILY BACKGROUND
24 SPOUSE'S SURNAME RUBI 25 NAME OF CHILD (Write full and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME JEOBE Carlsbyrth M. Rubi 03/02/09
MIDDLE NAME MONTANEZ Carlo Jheob Walter M. Rubi 03/26/14
OCCUPATION SECURITY GUARD
EMPLOYER'S NAME CANTILAN BANK
BUSINESS ADDRESS TANDAG CITY
TELEPHONE NO.
(Continue on separate page if necessary)
26 FATHER'S SURNAME MONTERO SR

FIRST NAME WALTER

MIDDLE NAME MONTENEGRO
27 MOTHER'S MAIDEN NAME

SURNAME BAGONA
FIRST NAME SOLIDAD
MIDDLE NAME ALAMIDA (Continue on separate sheet if necessary)

III EDUCATIONAL BACKGROUND

28 YEAR HIGHEST GRADE/ INCLUSIVE DATES OF SCHOLARSHIP/
LEVEL NAME OF SCHOOL DEGREE COURSE GRADUATED LEVEL/ ATTENDANCE ACADEMIC HONORS
(Write in full) (Write in full) (if graduated) UNITS EARNED RECEIVED
From To
(If not graduated)

ELEMENTARY Falcon Memorial Elementary School N/A 2002 N/A 1996 2002 N/A

SECONDARY Purisima School N/A 2006 N/A 2002 2006 N/A

VOCATIONAL/ TRADE
N/A N/A N/A N/A
COURSE

Bachelor of Secondary
COLLEGE Surigao del Sur State University 2012 N/A 2006 2012 N/A
Education

GRADUATE STUDIES N/A N/A

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005) Page 1 of 4
Purok Citrus I, Barangay Purisima, Tago, 0
Surigao del Sur

Purok Citrus I, Barangay Purisima,

Tago, Surigao del Sur
IV. CIVIL SERVICE ELIGIBILITY
29 LICENSURE (if applicable)
DATE OF
CAREER SERVICE/ RA1080 (BOARD/BAR) UNDER
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT DATE OF
SPECIAL LAWS/ CES/ CSEE NUMBER
CONFERMENT RELEASE

LET(LICENSURE EXAMINATION FOR

79.80 3/10/2013 CAGAYAN DE ORO CITY 119575
TEACHERS)

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (include private employment. Start from current work)
30
INCLUSIVE DATES (mm/dd/yyyy) SALARY GRADE &
MONTHLY STATUS OF
STEP INCREMENT
SALARY APPOINTMENT
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY (Format 00-0) GOV'T SERVICE
From To (Write in full) (Write in full) (Yes / No)

7/8/2015 1/5/2018 TEACHER I VICENTE L. PIMENTEL SR. NATIONAL HIGH SCHOOL GRADE 11 PERMANENT YES

11/7/2012 7/7/2015 VOLUNTEER TEACHER VICENTE L. PIMENTEL SR. NATIONAL HIGH SCHOOL N/A VOLUNTEER YES

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005) Page 2 of 4
VI. VOLUNTARY WORK OR IMVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATIONS
31 INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION NUMBER OF
(mm/dd/yyyy)
HOURS
(Write in full) From To

N/A

(Continue on separate sheet if necessary)

VII. TRAINING PROGRAMS (Start from the most recent training)
32 INCLUSIVE DATES OF
ATTENDANCE (mm/dd/yyyy) NUMBER OF
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES HOURS
(Write in full) From To

21st CRAM Refresher course in Sports Coaching 8/24/2017 8/26/2017 24 hours

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION
33 34 NON-ACADEMIC DISTINCIONS / RECOGNITION
SPECIAL SKILLS / HOBBIES
(Write in full)
SPORTS ENTHUSIAST N/A

COMPUTER LITERATE N/A

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005
CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATIONS

POSITION / NATURE OF WORK

(Continue on separate sheet if necessary)

CONDUCTED / SPONSORED BY
(Write in full)

DEPED CARAGA

(Continue on separate sheet if necessary)

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION (Write
in full)
 LEAGUE OF TEACHER EDUCATION
STUDENTS

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005) Page 3 of 4
36 Are you related by sanguinity or affinity to any of the following:
a. Within the third degree (by National Government Employees): YES ✘ NO

appointing authority, recommending authority, chief of office/bureau/department of person who if YES, give details:
has immediate supervision over you in the Office, Bureau or Department where you will be _________________________________
appointed? _________________________________
_________________________________

b. Within the fourth degree (for Local Government Employees): YES ✘ NO

appointing authority or recommending authority where you will be appointed? if YES give details:
_________________________________
_________________________________
_________________________________
37 a. Have you been formally charged? YES ✘ NO
if YES give details:
_________________________________
_________________________________
b. Have you been guilty of any administrative offense? YES ✘ NO

if YES give details:

_________________________________
_________________________________
38 Have you ever been convicted of any crime or violation of any law, decree, ordinance or YES ✘ NO
regulation by any court or tribunal? if YES give details:
_________________________________
_________________________________
39 Have you ever been separated from the service in any of the following modes: resignation ✘ YES ✘ NO0
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or
phased out, in the public or private sector? if YES give details:
Due to transfer of residence
Transfer of Residence
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 © 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 differently abled? YES ✘ NO
if YES, please specify:
c Are you a solo parent? YES ✘ NO
if YES, please specify:
42 REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TEL. NO.

POYAN M. SECLON TAGO, SURIGAO DEL SUR

DOROTHY L. SUAZO TANDAG CITY
ERLINDA O MONTENEGRO TAGO, SURIGAO DEL SUR
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.
 GSIS
Government issued ID

2004791062
ID/License SIGNATURE (Sign inside the box)

TANDAG CITY January 5, 2018

Place of Issuance DATE ACCOMPLISHED

CS FORM 212 (Revised 2005

 ✘ NO

_______________________________________
_______________________________________
_______________________________________

✘ NO

_______________________________________
_______________________________________
_______________________________________
✘ NO

_______________________________________
_______________________________________
✘ NO

_______________________________________
_______________________________________
✘ NO

_______________________________________
_______________________________________
✘ NO

Due to transfer of residence

Transfer of Residence
✘ NO

_______________________________________
_______________________________________

✘ NO
if YES, please specify:
✘ NO
if YES, please specify:
✘ NO
if YES, please specify:

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
 RIGHT THUMBMARK

CS FORM 212 (Revised 2005) Page 4 of 4