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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET


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

I. PERSONAL INFORMATION
2. SURNAME ELAURZA
FIRST NAME AMELDA
MIDDLE NAME REDENCIO 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 11/23/1962 Kay Talise St. San Dionisio Parañaque
City
5. PLACE OF BIRTH Manila 16. RESIDENTIAL ADDRESS

6. SEX Male ü
qFemale

qSingle qWidowed ZIP CODE 1700


7. CIVIL STATUS ü
qMarried qSeparated 17. TELEPHONE NO.

qAnnulledqOthers, specify _______ Kay Talise St. San Dionisio Parañaque


City
8. CITIZENSHIP Filipino 18. PERMANENT ADDRESS

9. HEIGHT (m) 5'2 m


10. WEIGHT (kg) 120 lbs. ZIP CODE 1700
11. BLOOD TYPE O 19. TELEPHONE NO.

12. GSIS ID NO. 62112101166 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 0003-481145-01 21. CELLPHONE NO. (if any) 09061475066
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN 151-145-154


II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME Elaurza 25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH (mm/dd/yyy

FIRST NAME Job Charlon R. Elaurza 09/26/1990


MIDDLE NAME R. Milan R. Elaurza 04/09/1996
OCCUPATION Auto Electrician Marvin R. Elaurza 08/30/1997
EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME REDENCIO


FIRST NAME DIOSCORO
MIDDLE NAME R.
27. MOTHER'S MAIDEN NAME RODRIGUEZ
SURNAME REDENCIO
FIRST NAME EUFROCINA
MIDDLE NAME R. (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


HIGHEST
GRADE/ INCLUSIVE DATES OF
NAME OF SCHOOL DEGREE COURSE YEAR GRADUATED LEVEL/ ATTENDANCE
28. LEVEL
(Write in full) (Write in full) (if graduated) UNITS EARNED From To
(if not
graduated)
Elementary 0/00/19 0/00/19
ELEMENTARY Taguig Elementary School 1975
Graduate 69 75
Parañaque National Highschool 0/00/19 0/00/19
SECONDARY 1979
Highschool Graduate 75 79
VOCATIONAL /

TRADE COURSE

1983 00/00/1 0/00/19


COLLEGE Olivarez College 2 yrs. Jr. Sec.
981 83

Southeastern 00/00/1 00/00/1


1989 B.S.E Graduate
College 984 989

Pamantasan ng Lungsod ng
GRADUATE STUDIES 9 units
Maynila

(Continue on separate sheet if necessary)


ELAURZA, AMELDA REDENC
NAL DATA SHEET
(to be filled up by CSC)

Kay Talise St. San Dionisio Parañaque


City

1700

Kay Talise St. San Dionisio Parañaque


City

1700

09061475066

151-145-154

DATE OF BIRTH (mm/dd/yyyy)

09/26/1990
04/09/1996
08/30/1997

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

ue on separate sheet if necessary)


Page 1 of 4

ELAURZA, AMELDA REDENCIO


IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER
CONFERMENT

PBET 70.86% 10/25/1992 Manila 0/94/86

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES POSITION TITLE
DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
(Write SALARY INCREMENT APPOINTMENT
in full) (Format "00-0")
From To (Write in full)

18.00 a
06/13/1982 06/18/1989 School Clerk Parañaque National High School casual
day

06/19/1989 06/03/1994 Teacher I - do -

(Continue on separate sheet if necessary)


Page 2 of 4

ELAURZA, AMELDA REDENCIO


LICENSE (if applicable)
DATE OF
RELEASE

10/29/1997

e on separate sheet if necessary)

tart from your current work)


GOV'T SERVICE

(Yes / No)

e on separate sheet if necessary)


Page 2 of 4

ELAURZA, AMELDA REDENCIO


VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES NUMBER OF
31. POSITION / NATURE OF WORK
(Write in full) (mm/dd/yyyy) HOURS
From To
Member
Member

(Continue on separate sheet if necessary)


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

School Base In-Service traning 05/31/2006 06/01/2006 16 hrs. PNHS

Division Coaches Traning Workshop 04/24/2006 04/28/2006 40 hrs. Div. of P'que

Physical Seminar - Workshop 05/27/1999 05/29/1999 Div. of P'que

Physical Educ. Sports & Music

for Sec. PEHM Teachers

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION MEMBERSHIP IN


ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION:
33. SPECIAL SKILLS / HOBBIES: 34. 35.
(Write in full) (Write in full)

(Continue on separate sheet if necessary)


Page 3 of 4

ELAURZA, AMELDA REDENCIO


36.Are you related by consanguinity or affinity to any of the following :

a. Within the third degree (for National Government Employees): appointing authority, ü

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

b. Within the fourth degree (for Local Government Employees): appointing authority or ü

 YES 
recommending authority where you will be appointed? If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37.a. Have you ever been formally charged? ü

 YES 
If YES, give details:
________________________________
________________________________

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

 YES 
If YES, give details:
________________________________
________________________________

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

 YES 
or 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: ü

 YES 
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:
________________________________
________________________________

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

 YES 
election)? If YES, give details:
________________________________
________________________________

Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled
4
Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer
1.
the following items:
a. Are you a member of any indigenous group? ü

b. Are you differently abled?


 YES 
If YES, please specify: ____________________

c. Are you a solo parent?


 YES 
If YES, please specify: ____________________

 YES 
If YES, please specify: ____________________

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

NAME ADDRESS TEL. NO.

1. Emilie N. Batula Bernabe Subd. Phase 2 ID picture taken within


the last 6 months
2. Teresita B. Mula Imus Cavite 3.5 cm. X 4.5 cm
(passport size)
3. Alma Gloria Marquez San Dionisio P'que. City
Computer generated
43. Ideclare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines.

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

12633328
COMMUNITY TAX CERTIFICATE NO.

PARAÑAQUE CITY
ISSUED AT SIGNATURE (Sign inside the box)

01/06/2009 12/04/2009
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

Page 4 of 4
ELAURZA, AMELDA REDENCIO
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

If YES, give details:


_____________________________________
_____________________________________
_____________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, give details:


________________________________
________________________________

If YES, please specify: ____________________

If YES, please specify: ____________________

If YES, please specify: ____________________

Page 4 of 4
ELAURZA, AMELDA REDENCIO
PERSONAL
PERSONAL INFORMATION
Employee No. 8127052
Prefix First Name Middle Name Last Name Suffix
AMELDA REDECIO ELAURZA 0
Gender Date of Birth Place of Birth
Female 11/23/1962 Taguig City
Civil Status Citizenship
Single Filipino
Height Weight Blood Type
5'2.1/2 120lbs O
POLICY INFORMATION
GSIS Policy No. GSIS ID SSS No.
62112101166 0
PhilHealth Number TIN Pag-Ibig Code/ No.
151-145-254 0003-481145-01
CONTACT INFORMATION
Kay Talise St. Sn.
Residential Address: Dionision
Zip Code Parañaque
1700 city
Telephone No: 0
Kay Talise St. Sn.
Permanent Address: Dionision
Zip Code Parañaque
1700 city
Tel No. 0
Email:
Mobile No. 0906-1475-066

EMPLOYMEN
T
EMPLOYMENT INFORMATION
Employer Department of Education
Station Information
Station Name Station Code Station/School Type
307 502 Secondary
Business Address Telephone No.
Kay Talise St. Sn. Dionision Parañaque city

Information Staff Type Status Funding


Teaching Staff Employee is Active. Teacher has Coordinatorship Nationally Funded
Level Information (For Teaching Staff)
Grade/ Year Level Major Subject Level Subjects
SECOND YEAR Araling Panlipunan Multilevel
PSU Information
Hire Date Position Code

Payment Type Account No. Tax Code

FAMILY
FAMILY BACKGROUND
Parents Information First Name Middle Name Last Name
Father's Name: Dioscoro R. Redecio
First Name Middle Name Last Name
Mother's Name: Eufronina R. Redecio
Parents' Address Kay Talise St. Sn. Dionision Parañaque city
Spouse's Information First Name Middle Name Last Name
Name of Spouse Job R. Elaurza
Occupation Auto Electrician
Employer Name Jose
Business Address BF Homes P'que City
Tel. No. None
Children
NAME BIRTHDATE STATUS NAME BIRTHDATE STATUS
Charlon R. Elaurza 09/26/1990 single 0 12/30/1899
Milan R. Elaurza 04/09/1996 single 0 12/30/1899
Marvin R. Elaurza 08/30/1997 single 0 12/30/1899
0 12/30/1899 0 12/30/1899
0 12/30/1899 0 12/30/1899

EDUCATION
No. of Units
Honors
LEVEL NAME OF SCHOOL DEGREE COURSE Year Graduated Completed/ From To
Received
Course Title
Elementary
Elementary Taguig
Pque Elem
National Elem Grad 1975 1969 1975 0
Graduate
Highschool
Secondary H.S. H.S Grad 1974 1975 1979 0
Graduate 2
Tertiary Southern College B.S.E. Grad 1989 yrs. Jr. Sec. 1984 1989
Masters 9 units 0 12/30/1899 ### 0

ELIGIBILITY
License
Name Rate Exam Date Place Number Release Date
PBST 70.86% oct. 25 1992 Manila 914186 10/29/1997
0 0.00% 12/30/1899 0 0 12/30/1899
VOLUNTARY
Organization Inclusive Dates Position/Nature
No. of Hours
Name/Address From To of Work
12/30/1899
12/30/1899

TRAININGS
Inclusive Dates
Seminar Title/ Conference/ Workshop No. of Hours Conducted By
From To
School Base In-Service Training 05/31/2006 06/01/2006 16 PNHS
Division Coaches Training Workshop 04/24/2006 04/28/2006 40 DIV. Of P'QUE
Division Seminar-Workshop in 05/27/1999 05/29/1999 DIV. Of P'QUE
Physical Education, Sports & Music
for Sec. PEHM Teachers

0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0
0 12/30/1899 12/30/1899 0 0

SKILLS (Please use comma)


Description/Skills: 0 0 0 0 0 0

RECOGNITIONS (Please use comma)


Description/Recognitions Received 0 0 0 0 0 0

ORGANIZATIONS (Please use comma)


Description/Organization 0 0 0 0 0

OTHERS
36.
a. Are you
Within therelated by consanguinity
third degree or affinity
(For NATIONAL any of the
GOVERNMENT following: appointing authority, recommending authority, chief of
Employees):
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 your answer is "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 your
37. Formal answer is "YES", give details. _____________________________________________________________________
Charges
a. Have you ever been formally charged?
YES ✘ NO
If your answer is "YES", give details of the offense. ___________________________________________________________
YES offense?
b. Have you ever been guilty of any administrative ✘ NO

If your
38. Have youanswer is "YES",
ever been give details
convicted of anyof the offense.
crime ___________________________________________________________
or violation of any law, decree, ordinance or regulations by any court or
tribunal? YES ✘ NO

If your answer is "YES", give details of the offense. ___________________________________________________________


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, finishedYES
contract,
✘ NO AWOL or phased out, in the public or private sector?
If your answer is "YES", give reasons. _____________________________________________________________________
40. Have you ever been a candidate in a national or local election (except
YES Barangay
✘ NO Election)?
If your answer is "YES", give date of election and other particulars. ______________________________________________
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 indigenousYES group?✘ NO
If your answer is "YES", please specify. ____________________________________________________________
b. Are you differently abled?
YES ✘ NO
If your answer is "YES", please specify. ____________________________________________________________
c. Are you a solo parent?
YES ✘ NO
If your answer is "YES", please specify. ____________________________________________________________
Community Tax Information
COMMUNITY TAX ISSUED AT ISSUED ON
No.
12633328 PARAÑAQUE CITY 01/06/2009
REFERENCES
Name Address Telephone
Bernabe Subd.
Emilie N. Batula 0
Phase 2
Teresita B. Mula Imus Cavite 0
Alma Gloria Sn. Dionisio,
0
Marquez Pque. City