CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

1. CS ID No.

with check ( ) and use separate sheet if necessary

(to be filled up by CSC)

I.PERSONAL INFORMATION
2. SURNAME
FIRST NAME
MIDDLE NAME

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

5. PLACE OF BIRTH

C I E R
10/25/1965

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

16. RESIDENTIAL
ADDRESS

N/A

Camp Bado Dangwa, La Trinidad, Benguet

Dalayap, Langiden, Abra

6. SEX

Male

7. CIVIL STATUS

Female
ZIP CODE

Single

17. TELEPHONE NO.

(074) 422-55-15
Dalayap, Langiden, Abra

18. PERMANENT
ADDRESS
8. CITIZENSHIP

Filipino

9. HEIGHT (m)

1.62

10. WEIGHT (kg)

60

2601

2807
ZIP
CODE

11. BLOOD TYPE

N/A

12. GSIS POLICY NO.

N/A

13. PAG-IBIG NO.

1290-0036-65-16

14. PHILHEALTH NO.

04-000040543-6

19. TELEPHONE NO
20. E-MAIL ADDRESS (if
any)
21. CELLPHONE NO. (if
any)
22. AGENCY EMPLOYEE
NO.

15. SSS NO.

N/A

23. TIN

N/A
09175384459
N/A
154-637-291

II. FAMILY BACKGROUND

24. SPOUSES SURNAME

N/A

25. NAME OF CHILD (Write full name and list

all)

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME

N/A

Ysrael Anthony B Castillo

10/25/2002

MIDDLE NAME

N/A

Denmark Anthony C Navalta

07/07/2006

OCCUPATION

N/A

EMPLOYER/BUS
NAME
BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

N/A

26. FATHERS SURNAME

Navalta

FIRST NAME

Honorato

MIDDLE NAME

Papagayo

05/16/1928

27. MOTHERS MAIDEN NAME

SURNAME

Fonacier

FIRST NAME

Josefa

MIDDLE NAME

Ricafort

09/17/1930

III. EDUCATIONAL BACKGROUND

28.
LEVEL

NAME OF SCHOOL
(Write in full)

DEGREE/COURSE
(Write in full)

YEAR
GRADUATED
(if
graduated)

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

INCLUSIVE DATES
OF
ATTENDANCE
From

To

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

N/A

ELEMENTARY

Langiden Central School

N/A

1977

1971

1977

SECONDARY

St. Mary High School

N/A

1981

1977

1981

N/A

N/A

N/A

N/A

1984

1990

N/A

N/A

VOCATIONAL/
TRADE COURSE

COLLEGE

GRADUATE
STUDIES

N/A
Abra State Institute of
Sciences and
Technology
N/A

Bachelor of
Secondary
Education
N/A

N/A

1990

N/A

N/A

N/A
N/A
N/A
N/A
Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/RA 1080 (BOARD/Bar)
UNDER SPECIAL LAWS.CES/CSEE

N/A

RATING

N/A

DATE OF
EXAMINATION/
CONFERMENT

PLACE OF EXAMINATION/ CONFERMENT

N/A

N/A

LICENSE (if applicable)

NUMBER
DATE OF
RELEASE

N/A

N/A

V. WORK EXPERIENCE
30.

(include private employment, Start from most recent work experience)

INCLUSIVE DATES
(mm/dd/yyyy)
From

POSITION TITLE
(Write in full)

DEPARTMENT/AGENCY/OFFICE/CO
MPANY

MONTHLY SALARY

To

SALARY
GRADE &
STEP
INCREMEN
T

01/26/2011

Present

Mobility PNCO

RLRDD, PRO Cordillera

P 25,394.00

18

04/18/2005

04/19/2005

ROPD, PRO Cordillera

P 16,552.00

17

09/21/2002

04/17/2005

16-2

05/29/2005

Langiden MPS, Abra

PPO
PHQ, Abra PPO

P 12,375.00

09/20/2002

P 10,875.00

14-2

07/15/1994

05/28/2002

Operations
PNCO
Operations
PNCO
Operations
PNCO
Plans PNCO

ROPD, PRO Cordillera

8,758.00

12-1

04/11/1992

07/14/1994

Rifleman

RMG, PRO Cordillera

1,800.00

10-1

09/16/1991

04/10/1992

Police Trainee

PNP Training Command

1,000.00

10-1

STATUS OF
APPOIN
MENT

GOVT
SERVICE
(Yes/No)

Permane
nt
Permane
nt
Permane
nt
Permane
nt
Permane
nt
Permane
nt
Permane
nt

Yes
Yes
Yes
Yes
Yes
Yes
Yes

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

31.
NAME & ADDRESS OF ORGANIZATION
(Write in full)

N/A

INCLUSIVE DATES
(mm/dd/yyyy)
From
To

N/A

N/A

NUMBER OF
HOURS

POSITION/NATURE OF WORK

N/A

N/A

VII TRAINING PROGRAMS (Start from the most recent training)

32.

INCLUSIVE DATES (mm/dd/yyyy)

TITLE OF SEMINAR/CONFERENCE/WORKSHOP
(Write in full)

From

Police Basic Course

PNP Special Counter Operations Unit
Criminal Investigation and Detection
course
Public Safety Junior Leaderships Course
Public Safety Senior Leadership Course

To

NUMBER OF
HOU
RS

CONDUCTED/SPONSORED BY
(Write in full)

09/16/1991
11/03/1993
01/20/1977

03/09/1992
12/18/1993
06/20/1977

800
200
800

PNP Training Command

PNP Special Action Force
Regional Training School - CAR

05/04/2001
10/15/2009

09/29/2001
01/30 2010

400
560

Regional Training School - CAR

Regional Training School 1

VIII. OTHER INFORMATION

33.

34.
SPECIAL SKILLS/HOBBIES

Basic Computer Operation

NON-ACADEMIC DISTINCTIONS/RECOGNITION
(Write in full)

35.

MEMBERSHIP/
ASSOCIATION/ORGANIZATION
(Write in full)

Medalya Kagalingan 8

N/A

Medalya ng Kasanayan - 13
Medalya ng Papuri - 17
Medalya ng Mabuting Asal - 4
Medalya ng Pakikipaglaban sa
Manliligalig - 3
Medalya ng Pagtulong sa Nasalanta 1

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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
persons who 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
If YES, give details:

YES

NO

Appointing authority or recommending authority where you will be appointed?

If YES, give details:

37. a. Have you ever been formally charged?

YES
NO
If YES, give details:

B . Have you ever 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 regulations by any court or tribunal?

YES
NO
If YES, give details:

39. Have you ever been forced to retired/resign or dropped from employment in the public
or private sector?

YES
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 Peoples Act (RA 8371); (b) Magna Carta for Disabled
Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (8972)*; please answer the
following items:
a.

Are you a member of any indigenous group?

YES
NO
If YES, give details: Tingguian

b.

Are you differently abled?

YES
NO
If YES, give details:

c.

Are you a solo parent?

YES
NO
If YES, give details:

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

NAME

ADDRESS

PSSUPT DAVID Q LACDAN

PSSUPT DONATO O BACQUIAN
PSUPT REGUEL B SNTAMARIA

TELEPHONE NO.

Camp Bado Dangwa, La Trinidad, Benguet

Camp Bado Dangwa, La Trinidad, Benguet
Camp Bado Dangwa, La Trinidad, Benguet

422-5435
422-5435
422-5435

42. I declare under oath the penalties of perjury that this Personal Data Sheet has been accomplished in good faith, verified by me and to
the best of my knowledge and belief 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/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

Computer generated
Or Xerox copy of picture
Is not acceptable
PHOTO

06455818
COMMUNITY TAX CERTIFICATE NO.

LA TRINIDAD, BENGUET
ISSUED AT

SIGNATURE

11/13/2013

12/02/2013

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED
RIGHT THUMBMARK

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