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
ABRINA

2. SURNAME
FIRST NAME

KENAN

MIDDLE NAME

LAVEGA

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

5. PLACE OF BIRTH

16. RESIDENTIAL ADDRESS

8/27/1994

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

BAGONG BAYAN, EL NIDO, PALAWAN

Male

6. SEX
7. CIVIL STATUS

BAGONG BAYAN, EL NIDO, PALAWAN

Female

Single

Widowed

Married

Separated

Annulled

Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP

Filipino

9. HEIGHT (m)

5'7"

ZIP CODE

5313
NONE

17. TELEPHONE NO.

BAGONG BAYAN, EL NIDO, PALAWAN

10. WEIGHT (kg)

54 kg

11. BLOOD TYPE

19. TELEPHONE NO.

NONE

12. GSIS ID NO.

N/A

20. E-MAIL ADDRESS (if any)

kenanabrina@rocketmail.com

13. PAG-IBIG ID NO.

N/A

21. CELLPHONE NO. (if any)

09460444000

14. PHILHEALTH NO.

09-025439846-1

22. AGENCY EMPLOYEE NO.

N/A

15. SSS NO.

04-27228368

23. TIN

322-266-286

ZIP CODE

5313

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME

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

N/A

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

N/A

MIDDLE NAME

N/A

OCCUPATION

N/A

EMPLOYER/BUS. NAME

N/A

BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

ABRINA

FIRST NAME

FLORESTO

MIDDLE NAME

SALDIVAR

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME

27. MOTHER'S MAIDEN NAME

SURNAME

LAVEGA

FIRST NAME

PUJRISIMA

MIDDLE NAME

LAGRADA

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

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

DEGREE COURSE
(Write in full)

full)

(if graduated)

INCLUSIVE DATES OF
ATTENDANCE
From

To

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

ELEMENTARY

BAGONG BAYAN, ELEM. SCHOOL

GRADUATE

2005

GRADUATE

6/1999

03/2005

WITH HONORS

SECONDARY
VOCATIONAL /

BAGONG BAYAN, NAT'L HIGH SCHOOL

GRADUATE

2010

GRADUATE

6/2005

4/2010

WITH HONORS

FULLBRIGHT COLLEGE, PUERTO

PRINCESA CITY

BS. CRIM

2014

GRADUATE

6/2010

4/2014

NONE

N/A

N/A

COLLEGE
COURSE

TRADE

GRADUATE STUDIES

N/A

(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

LICENSURE EXAM. FOR TEACHERS

RATING

75.00%

LICENSE (if applicable)

DATE OF
EXAMINATION /
CONFERMENT

8/26/2001

PLACE OF EXAMINATION / CONFERMENT

PALAWAN NATIONAL SCHOOL

NUMBER

733908

DATE OF
RELEASE

11/15/2001

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.

INCLUSIVE DATES
(mm/dd/yyyy)
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)

7/3/2000

12/4/2005

TEACHER I

BAGONG BAYAN NHS

3,000.00

10-1

(Locally
paid)

YES

12/5/2005

to present

TEACHER I

BAGONG BAYAN NHS

19,12200

11-3

REG.PER

YES

/
(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

31. NAME & ADDRESS OF ORGANIZATION

INCLUSIVE DATES
(Write in full)

NUMBER OF
HOURS

(mm/dd/yyyy)
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)

(mm/dd/yyyy)
From

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

To

MASS TRAINING OF YEAR II TEACHERS ON THE 2010 SEC

5/10/2011

5/13/2011

36

DEPED

DIVISION EDUC.DEV'T PLAN 2011-2016 CONSULTATIVE

CONFERENCE

12/20/2010

12/21/2010

24

DEPED

2010 DIVISION SEMINAR WORKSHOP ON GENDER AND

DEVELOPMENT

12/21/2010

DEPED

DIVISION EDUCATION DEV'T PLAN WORKSHOP

10/21/2010

10/22/2010

24

DEPED

MASS TRAINING OF YEAR I TEACHERS ON THE 2010 SEC

6/7/2010

6/11/2010

40

DEPED

CLUSTER ORIENTATION WORKSHOP ON THE 2009 NATIONAL

10/5/2009
TEXTBOOK DELIVERY AND SUPPLY/PROPERTY MGT PROG.
REORIENTATION ON SCHOOL MGT FOR SECONDARY
SCHOOL HEADS

8/6/2009

8
8/7/2009

16

NAPSSHI

DIVISION ROLL-OUT OF SBM,SIP,SGC,NCBTS,TSNA AND IPPD

5/19/2009
ADVOCACY

5/23/2009

36

DEPED

FIRST REGIONAL PUBLIC SECONDARY SCHOOL HEAD

FORUM

2/27/2008

2/29/2008

24

NAPSSHI

10/24/2007

7/23/2007

7/25/2007

24

DEPED

ADMINISTRATIVE CASES AND ON THE POLL DUTIES OF

TEACHERS.

3/7/2007

3/8/2007

16

DEPED

BASIC EDUCARION REFORM AGENDA FOR SEC. TEACHERS

11/16/2007

DEPED

3/1/2007

DEPED

10/25/2010

2007 NATIONAL TEXTBOOK DELIVERY PROGRAM CLUSTER

ORIENTATION WORKSHOP
DIVISION ON ORIENTATION ON ADOPT A SCHOOL PROGRAM
FOR PSDS,COORDINATING PRIN.MASP COOR,AND
SEC,SCHOOL
SCHOOL
SEEMINAR ONPRIN./
REVISED
RULESHEAD
OF PROCEDURE FOR

THE DIVISION ECHO TRAINING ON SCHOOL MAPPING

EXERCISE AND ORIENTATION OF THE GIS BASED SCHOOL
PROFILING SYSTEM.
CONFERENCE WORKSHOP PHILIPPINE EFA PLAN 2015 AND
OTHER STATISTICAL IMPROVEMENT ACTIVITIES.

DEPED

(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)

(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):

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?

YES
NO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

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
regulation by any court or tribunal?

39.

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?

40.

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

YES
NO
If YES, give details:
________________________________
________________________________
YES

NO

If YES, give details:

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

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.

Computer generated
or xerox copy of picture
is not acceptable

PHOTO

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK

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