Escolar Documentos
Profissional Documentos
Cultura Documentos
I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME 4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS
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| S |H | A | N | E | 09/29/1983
A | B | I | N |G | O |N | A |
| N/A |
QUEZON CITY
Male Single Married Annulled Female Widowed Separated
17. TELEPHONE NO. ZIP CODE
1126 N/A
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.
N/A
/ / / / / / / / / / /
/ / / / / / / / / / / / /
/ /
(if graduated)
QUIRINO ELEMENTARY SCHOOL ROOSEVELT COLLEGE-QUIRINO N/A POLYTECHNIC UNIVERSITY OF THE PHILIPPINES-STA. MESA
PRIMARY SECONDARY
1996 2000
GRADUATED GRADUATED
1990 1996
1996 2000
N/A N/A
2004
GRADUATED
2000
2004
GRADUATE STUDIES
N/A
CS-SUBPROFESSIONAL
CSC-NCR (CAT)
209081WE
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. From INCLUSIVE DATES (mm/dd/yyyy) To POSITION TITLE (Write in full) DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)
MONTHLY SALARY
SALARY GRADE & STEP INCREMENT (Format "00-0")
STATUS OF APPOINTMENT
ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III ADMIN AIDE III CLERK I
AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER AFP MEDICAL CENTER
/ / / / /
/ / / / /
/ / / / /
/ / / / /
VALUES ORIENTATION WORKSHOP CIVILIAN PERSONNEL BASIC COURSE CLASS 21-2011 SEMINAR ON PUBLIC SERVICE ETHICS AND ACCOUNTABILITY (PSEA) SERVICE ETIQUETTE AND PROTOCOL SEMINAR CLASS 02-2008 CIVILIAN PERSONNEL BASIC ORIENTATION SEMINAR CLASS 11-2004
1. LETTER OF COMMENDATION FROM BGEN ARIEL A ZERRUDO AFP DTD 01 JANUARY 2010 2. LETTER OF COMMENDATION FROM COL TYRONE O NONATO MAC (GSC) DTD 29 NOV 2009 3. LETTER OF COMMENDATION FROM BGEN ARIEL A ZERRUDO AFP DTD 30 JANUARY 2009
4. CERTIFICATE OF RECOGNITION FROM DRA CHERILYN R LUZANO MD, CEA PRESIDENT DTD 29 AUG 2008
5.LETTER OF COMMENDATION FROM BGEN EFREN O VERAN AFP DTD 25 JUN 2007
(Continue on separate sheet if necessary) CS FORM 212 (Revised 2005), Page 3 of 4
36. a.
Are you related by consanguinity or affinity to any of the following : 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? Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________
b.
37
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)?
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
OFFICE OF THE DEPUTY COMMNADER FOR ADMIN, AFP MEDICAL CENTER
TEL. NO.
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size)
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. 06482316
COMMUNITY TAX CERTIFICATE NO.
PHOTO
Quezon City
ISSUED AT SIGNATURE (Sign inside the box)
02/10/2012
ISSUED ON (mm/dd/yyyy)
03/19/2012
DATE ACCOMPLISHED RIGHT THUMBMARK