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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET


Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME

|B

|A

|C |A

|A |I |I

|R |R |V

|R |E |A | |

|O | |

| | |

| | |

| | |

| | |

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| |

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| | |

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| | |

|C |L |D

|A |L

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

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

01/15/1981

16. RESIDENTIAL ADDRESS

Panitan,Capiz Male Single Married Annull ed FILIPINO 1.59 55 "O" N/A 1080-0285-1736 03-000228055-4 07-3189435-2
ZIP CODE 19. TELEPHONE NO.

POBLACION SUR IVISAN,CAPIZ

Fem ale Widowed Separated


ZIP CODE 17. TELEPHONE NO.

5805 None

Others, specify ___________ PERMANENT ADDRESS 18. POBLACION SUR IVISAN,CAPIZ

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.

5805 None @ yahoo.com

20. E-MAIL ADDRESS (if any) clerskie

21. CELLPHONE NO. (if any)09214237497 22. AGENCY EMPLOYEE NO. 23. TIN

302-027-293-000

II. FAMILY BACKGROUND


24.SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. (Continue on separate sheet if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 25. NAME OF CHILD (Write full name and list DATE OF BIRTH (mm/dd/yyyy) all)

N/A

N/A

/ N/A / / / / / / / / / / / / / / / / / / / / / / / / /

BACARRO ( DECEASED) ALFREDO ABISAN

27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME

DALIVA TESSIE VENUS


YEAR GRADUATE D DEGREE COURSE (Write in full)

(Continue on separate sheet if necessary) HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated)

III. EDUCATIONAL BACKGROUND


28. LEVEL NAME OF SCHOOL (Write in full)

INCLUSIVE DATES OF ATTENDANCE From To

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

ELEMENTARY SECONDARY COLLEGE

IVISAN ELEMENTARY SCHOOL IVISAN NATIONAL HIGH SCHOOL FILAMER CHRISTIAN COLLEGE BACHELOR OF ELEMENTARY EDUCATION

(if 1993 graduated )

1987 1993 1999

1993 1997 2003

1997 2003

GRADUATE STUDIES

POST GRADUATE

(Continue on separate sheet if necessary)

IV. CIVIL SERVICE ELIGIBILITY


29. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING DATE OF EXAMINATIO N/ CONFERMENT
AUG. 14, 2005

LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE


OCT.7,2005

LICENSURE EXAMINATION FOR 75.00% TEACHERS (LET)

ILOILO,CITY

0900081

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES (mm/dd/yyyy) From To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY (Write in SALARY full)
SALARY GRADE & STATUS OF STEP APPOINTMEN INCREMENT T (Format "000")

GOV'T SERVICE

BUREAU OF FIRE PROTECTION LEAVE MNGT SECTION/PRMD PROTECTION BUREAU OF FIRE LEAVE MNGT SECTION/PRMD BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV BUREAU OF FIRE PROTECTION RECORDS SECTION/ADMIN.DIV FIRE NATIONAL TRAINING INSTITUTE

06/01/20 11

Present

FO2 / LEAVE PROCESSOR FO2 / LEAVE PROCESSOR FO2 / LEAVE PROCESSOR FO2 / LEAVE PROCESSOR FO1 / LEAVE PROCESSOR FO1 / LEAVE PROCESSOR FO1 / LEAVE PROCESSOR FO1 / LEAVE PROCESSOR FO1 / OJT FO1 / TRAINEE FO1 / OJT

15,359.00 13,785.00 13,785.00 12,210.00 10,808.00

PERM PERM PERM PERM PERM PERM PERM TEMP TEMP TEMP TEMP

No) YES

(Yes /

10/19/20 05/31/201 10 1 06/24/20 10/18/201 10 0 03/08/20 06/23/201 10 0 07/01/20 03/07/201 09 0 07/01/20 06/30/200 08 9 12/19/20 06/30/200 07 8 12/06/20 12/18/200 07 7 11/16/20 12/05/200 07 7 07/09/20 11/15/200 07 7 02/21/20 07/08/200 07 7

YES YES YES YES YES YES YES YES YES YES

9,466.00 8,605.00 8,605.00 8,605.00 8,605.00

BUREAU OF FIRE PROTECTION RECORDS 8,605.00 SECTION/ADMIN.DIV

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


INCLUSIVE DATES 31. NAME & ADDRESS OF ORGANIZATION (Write in full) (mm/dd/yyyy) From To NUMBER OF HOURS POSITION / NATURE OF WORK

N/A

/ / / /

/ / / /

/ / / /

/ / / /

N/A

(Continue on separate sheet if necessary)

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


32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full) INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy) To NUMBER CONDUCTED/ SPONSORED BY OF HOURS (Write in full)

From

CUSTOMER RELATIONS OFFICERS (CRO) SEMINAR SEMINAR ON ARSON INVESTIGATION AND EVIDENCE COLLECTION FOR FEMALE FIREFIGHTERS SEMINAR-WORKSHOP ON ADMINISTRATIVE MATTERS HOLY ROSARY MONTH AND HOLY EUCHARIST SEMINAR-WORKSHOP ON RECORDS MANAGEMENT AND LEAVE ADMINISTRATION SEMINAR-WORKSHOP ON RECORDS MANAGEMENT AND LEAVE ADMINISTRATION FIRE BASIC RECRUIT COURSE (FBRC) CLASS 2007-45 GAS ENGINE TUNE UP SOLDIERS OF CHRIST MOVEMENT,INC VALUE FORMATION PROGRAM BFP RECRUIT ORIENTATION PROGRAM

11/16/2010 11/17/2010 16 HRS 10/27/2010 10/29/2010 24 HRS

BUREAU OF FIRE PROTECTION BUREAU OF FIRE PROTECTION

BUREAU OF FIRE 04/19/2010 04/21/2010 24 HRS PROTECTION OFFICE OF THE RECORDS SECTION BUREAU OF FIRE 10/21/2009 10/22/2009 16 HRS PROTECTION CHAPLAIN SERVICE UNIT BUREAU OF FIRE 05/07/2009 05/08/2009 16 HRS PROTECTION OFFICE OF THE RECORDS SECTION BUREAU OF FIRE 04/14/2008 04/15/2008 16 HRS PROTECTION OFFICE OF THE RECORDS SECTION 07/09/2007 11/15/2007 640 HRS FIRE NATIONAL TRAINING INSTITUTE

TECHNICAL EDUCATION 10/11/2007 10/12/2007 16 HRS AND SKILLS DEVELOPMENT AUTHORITY 08/03/2007 08/05/2007 50 HRS RABBI APOSTOLATE TEAM 03/06/2007 03/28/2007 184 HRS BUREAU OF FIRE PROTECTION

(Continue on separate sheet if necessary)

VII OTHER INFORMATION I


33 SPECIAL SKILLS/HOBBIES 34
NON-ACADEMIC DISTINCTIONS/RECOGNITION (Write in full) 35 MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in Full)

COMPUTER LITERATE

MEDALYA NG PAPURI B.O # AWD-2009-342 MEDALYA NG KASANAYAN B.O # AWD-2008-442 MEDALYA NG PAPURI B.O # AWD-2008-300 MEDALYA NG KASANAYAN B.O # AWD-2008-293 MEDALYA NG PAPURI B.O # AWD-2008-091

AFPMBAI
AFPSLAI

CS FORM 212 (Revised 2005)

36. Are

you related by consanguinity or affinity to any of the following : YES NO If YES, give details: ____________________________________ _ ____________________________________ _ ____________________________________ YES NO _ If YES, give details: ____________________________________ _ ____________________________________ _ YES NO ____________________________________ If _ YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO If YES, give details: ________________________________ ________________________________ YES NO

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? the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?

b. Within

37 a.

Have you ever been formally charged?

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

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?

If YES, give details: ________________________________ ________________________________ YES NO

40. Have

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

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: Are you a member of any indigenous group? Are you differently abled? Are you a solo parent? YES NO If YES, please specify: ____________________ YES NO If YES, please specify: ____________________ YES NO If YES, please specify: ____________________

a. b. c.

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME ADDRESS TEL. NO.

NUP ROSITA J PARIZAL NUP ELOISA S BANAC

BFP-NHQ BFP-NHQ

995-7970

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

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. 24755174
COMMUNITY TAX CERTIFICATE NO.

PHOTO

Manila
ISSUED AT SIGNATURE (Sign inside the box)

03/29/2011
ISSUED ON (mm/dd/yyyy)

July 28, 2011


DATE ACCOMPLISHED RIGHT THUMBMARK CS FORM 212 (Revised 2005)