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 BATALAO
2. SURNAM SURNAME E FIRST NAME
DEXTER
MIDDLE NAME
GAYAWET
3. NAME EXTENSION (e.g. Jr., Sr.) 16. RESIDENTIAL ADDRESS
09/22/1985
4. DATE OF BIRTH (mm/dd/yyyy)
Tuguegarao City, Cagayan Male Female
5. PLACE OF BIRTH BIRTH 6. SE SEX X
Single Married
7. CIVIL STATUS
Widowed Separated Others, specify ___________
Annulled 8. CITIZENSH CITIZENSHIP IP
Filipino
9. HEIGHT HEIGHT (m) (m)
1.8 m
No. 345, Purok 7, Interior New Lucban, Baguio City, Benguet
ZIP CODE
2600 N/A
17. TELEPHONE NO. 18. PERMANENT ADDRESS
Purok 2, Bulanao Norte, Tabuk City, Kalinga
10. WEIGHT WEIGHT (kg)
70 kgs.
11. BLOOD BLOOD TYPE TYPE
"o"
19. TELEPHONE NO.
N/A
12. 12. GSIS ID NO.
N/A
20. E-MAIL ADDRESS (if any)
redxet_
[email protected] [email protected]
13. PAG-IBIG PAG-IBIG ID ID NO.
1210 1795 1385
21. CELLPHONE NO. (if any)
0999-999-8696
14. PHILHEALT PHILHEALTH H NO. NO.
N/A
22. AGENCY EMPLOYEE NO.
N/A
15. 15. SS SSS S NO. NO.
01 1847988 2
23. TIN
N/A
ZIP CODE
3800
II. FAMILY BACKGROUND 24. SPOUSE SPOUSE'S 'S SURNAME SURNAME
25. NAME OF CHILD (Write full name and list all)
N/A
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME
N/A
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MIDDLE NAME
N/A
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OCCUPATION
N/A
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EMPLOYER/BUS. NAME
N/A
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BUSINESS ADDRESS
N/A
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TELEPHONE NO.
N/A
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(Continue on separate sheet if necessary)
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BATALAO
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FIRST NAME
EUGENE
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MIDDLE NAME
MASSAGAN
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26. FATHER'S SURNAME
27. MOTHER'S MAIDEN NAME SURNAME
GAYAWET
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FIRST NAME
CORAZON
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MIDDLE NAME
BATALAO
(Continue on separate sheet if necessary)
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 HONORS RECEIVED
ELEMENTARY
BULANAO CENTRAL SCHOOL
ELEMENTARY
199 8
Graduated
19 9 2
1 99 8
With Honors
SECONDARY
KALINGA ACADEMY
HIGH SCHOOL
200 4
Graduated
20 0 3
2 00 4
With Honors
UNIVERSITY OF BAGUIO
Bachelor of Arts Major in Political Science
201 0
Graduated
20 0 8
2 01 0
Dean's Lister
VOCATIONAL / TRADE COURSE COLLEGE
GRADUATE STUDIES
(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
CAREER SERVICE PROFESSIONAL ELIGIBILITY
RATING
80.52%
DATE OF EXAMINATION / CONFERMENT
07/27/2008
LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER
BAGUIO CITY
DATE OF RELEASE
9/29/2008
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work) INCLUSIVE DATES (mm/dd/yyyy)
30.
From
POSITION TITLE (Write in full)
DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)
MONTHLY SALARY
To
SALARY GRADE & STEP INCREMENT (Format "00-0")
STATUS OF APPOINTMENT
GOV'T SERVICE (Yes / No)
SG-15
PERMANENT
Yes
JOB ORDER
Yes
COMPUTER MAINTENANCE TECHNOLOGIST II
Department of Public Works and Highways Kalinga District Engineering Office
06/01/2012
LEGAL AIDE
Department of Public Works and Highways P320.13/day Regional Office, CAR
03/02/2009
03/31/2010
SCHOLARSHIP LIAISON
House of Representatives - Lone District of Kalinga, Congressional District Office
P8,000.00/Mo. Honorarium
CASUAL
Yes
09/08/2008
02/27/2009
LEGISLATIVE STAFF
House of Representatives - Lone District of Kalinga, Congressional District Office
P8,000.00/Mo. Honorarium
CASUAL
Yes
04/16/2008
06/30/2008
MESSENGER
Department of Public Works and Highways P272.00/day Kalinga District Engineering Office
JOB ORDER
Yes
08/01/2007
01/11/2008
RECORD OFFICER
House of Representatives - Lone District of Kalinga, Congressional District Office
CASUAL
Yes
09/24/2012
To date.
11/22/2010
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P6,000.00/Mo. Honorariuum
(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 INCLUSIVE DATES (mm/dd/yyyy)
NAME & ADDRESS OF ORGANIZATION (Write in full)
31.
From
Pasil Student Organization (Tabuk Chapter)
NUMBER OF HOURS
POSITION / NATURE OF WORK
To
06/16/2008
06/01/2009
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Chapter President
(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) From
NUMBER OF HOURS
CONDUCTED/ SPONSORED BY in full)
(Write
To
Seminar on Asian Parliamentary Debate Format
09/17/2010
09/17/2010
8
Seminar on Asian Parliamentary Debate Format - 2009 Academic Olympics
09/19/2009
09/19/2009
8
Industry Clustering and Value Chain Assesment Workshop for Kalinga Coffee and Organic Rice
04/28/2009
04/30/2009
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University of Baguio - Office of Student Affairs University of Baguio - Office of Student Affairs and in coordination with the Soapbox Union Philippine Development Assistance Progamme Inc. and House of Representatives - Congressional District Office, Kalinga
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION 33.
SPECIAL SKILLS / HOBBIES:
DRIVING
34.
NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)
Certificate of Recognition: " Mr. LAGA 2008". For winning in the 2008 LAGA FASHION SHOW during the 2008 Kalinga Day Celebration. Awarded by the Office of the Governor Province of Kalinga.
35.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
PASIL STUDENT ORGANIZATION (P.S.O.TABUK CHAPTER) KALINGA-APAYAO STUDENT ASSOCIATION (BAGUIO) POLITICAL SCIENCE STUDENT ASSOCIATION (U.B.-POLITIS) PASIL STUDENT ORGANIZATION (BAGUIO-BENGUET CHAPTER) KALINGA LAW STUDENT ASSN. (BAGUIO-BENGUET CHAPTER)
READING TYPING BASIC COMPUTER OPERATION BASIC AUTOMOTIVE TROUBLESHOOTING (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.
39.
40.
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
If YES,YES give details:NO ________________________________ ________________________________
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?
YES
NO
If YES, give details: ________________________________ ________________________________
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 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: KALINGA 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
TEL. NO.
ADDRESS
GARY U. DAMIAN
Purok 2, Bulanao Norte, Tabuk City, Kalinga
0927-871-4192
SAMUEL BAYANGAN
Dagupan Centro, Tabuk City, Kalinga
0916-771-8099
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 representati ve 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 (passport size)
Computer generated or xerox copy of picture is not acceptable
PHOTO
33404331 COMMUNITY TAX CERTIFICATE NO.
BAGUIO CITY SIGNATURE (Sign inside the box)
ISSUED AT
06/01/2011 ISSUED ON (mm/dd/yyyy)
06/06/2011 DATE ACCOMPLISHED
RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4