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
S | A | L | E | N | G | A |

2. SURNAME

J | E | R | I | C | O |

FIRST NAME

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D | I | P | A | S | U | P | I | L |

MIDDLE NAME

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Male

6. SEX
7. CIVIL STATUS

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

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N/A

39 MANUEL L. QUEZON STREET, LOWER BICUTAN, TAGUIG,

METRO MANILA

MANDALUYONG

5. PLACE OF BIRTH

16. RESIDENTIAL ADDRESS

08/22/1984

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

Female

Single

Widowed

Married

Separated

Annulled

Others, specify ___________ 18. PERMANENT ADDRESS

(02) 837-5677

17. TELEPHONE NO.

39 MANUEL L. QUEZON STREET, LOWER BICUTAN, TAGUIG,

METRO MANILA

8. CITIZENSHIP

FILIPINO

9. HEIGHT (m)

1.63 METERS

10. WEIGHT (kg)

61 KILOGRAMS

1632

ZIP CODE

(02) 837-5677

11. BLOOD TYPE

19. TELEPHONE NO.

12. GSIS ID NO.

20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO.

121-123-462-960

21. CELLPHONE NO. (if any)

14. PHILHEALTH NO.

0105-1939-2580

22. AGENCY EMPLOYEE NO.

SSS NO.

1632

ZIP CODE

JERICOSALENGA@GMAIL.COM
09155511127

457-927-072

23. TIN

34-4774954-9

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME

25. NAME OF CHILD (Write full name and list all)

N/A

DATE OF BIRTH (mm/dd/yyyy)

N/A

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

SALENGA

ROGELITO

PAULE

FIRST NAME
MIDDLE NAME

26. FATHER'S SURNAME

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

DIPASUPIL

FIRST NAME

ANGELITA

MIDDLE NAME

DOMINGO

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.

YEAR
GRADUATED

NAME OF SCHOOL
LEVEL

(Write in

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

DEGREE COURSE
(Write in full)

full)

INCLUSIVE DATES OF
ATTENDANCE
From

To

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

1996

GRADE 6 ELEMENTARY

1993

1996

DIPLOMA

INTERMEDIATE

2001

4TH YEAR HIGH SCHOOL

1996

2001

DIPLOMA, ACAD.
DISTINCTION

DE LA SALLE UNIVERSITY

BA PSYCH AND
BSC LEGAL MGT

2005

BACHELOR OF
ARTS/COMM.

2001

2005

DIPLOMA

SAN BEDA COLLEGE ALABANG - SCHOOL

OF LAW

BACHELOR OF
LAWS

2014

BACHELOR OF
LAWS

2013

DIPLOMA

ELEMENTARY

COLEGIO DE STA. ANA

PRIMARY

SECONDARY
VOCATIONAL /

SAN BEDA COLLEGE - HIGH SCHOOL

(if graduated)

N/A
COLLEGE
COURSE

TRADE

GRADUATE STUDIES

2009

(Continue on separate sheet if necessary)

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29.

LICENSE (if applicable)

RATING

DATE OF
EXAMINATION /
CONFERMENT

PLACE OF EXAMINATION / CONFERMENT

RA 1080 (BAR)

76.00%

08/01/2013

UNIVERSITY OF STO. TOMAS, ESPANA

MANILA

CAREER SERVICE (Civil Service Elegibility)

PASSED

04/01/2014

QUEZON CITY

2014

REAL ESTATE BROKERS EXAM

78.00%

05/24/2015

COLLEGE OF THE HOLY SPIRIT, MENDIOLA

MANILA

2015

CAREER SERVICE/ RA 1080 (BOARD/ BAR)

UNDER SPECIAL LAWS/ CES/ CSEE

NUMBER

DATE OF
RELEASE

63010

2014

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.

INCLUSIVE DATES
(mm/dd/yyyy)

POSITION TITLE

DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)

From

To

05/25/2015

PRESENT

08/04/2015

(Write in full)

RETAINED ASSOCIATE
COUNSEL

GOV'T
SERVICE
MONTHLY
SALARY

SALARY GRADE
& STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT
(Yes / No)

GIMENEZ LAW OFFICE

PHP35000

PERMANENT

NO

02/27/2015 ASSOCIATE LEGAL COUNSEL

HECHANOVA BUGAY VILCHEZ

ANDAYA RACADIO

PHP32000

PROBATIONARY

NO

01/27/2014

07/31/2015

UNDERBAR ASSOCIATE

CAMACHO AND ASSOCIATES

PHP25000

PROBATIONARY

NO

06/27/2003

09/22/2003

ON THE JOB TRAINEE

OFFICE OF THE SOLICITOR GENERAL

N/A

OJT

YES

/
(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

31. NAME & ADDRESS OF ORGANIZATION

INCLUSIVE DATES
(Write in full)

(mm/dd/yyyy)

NUMBER OF
HOURS

POSITION / NATURE OF WORK

From

To

DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT

11/28/2013

11/28/2013

REPACKER OF RELIEF GOODS

BUREAU OF JAIL MANAGEMENT AND PENOLOGY

07/07/1905

07/07/1905

60

STUDENT LEGAL

(Continue on separate sheet if necessary)

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

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write
in full)

REAL ESTATE BROKERS LECTURE SERIES

(mm/dd/yyyy)
From

To

02/21/2015

05/18/2015

NUMBER OF
HOURS

120

CONDUCTED/ SPONSORED BY
(Write in full)

CITY OF TAGUIG REAL ESTATE

BOARD

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

33.

SPECIAL SKILLS / HOBBIES:

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

34.
(Write in full)

35.

MEMBERSHIP IN
ASSOCIATION/ORGANIZATION
(Write in full)

LEGAL RESEARCH

INTEGRATED BAR OF THE

PHILIPPINES

MUSIC

CITY OF TAGUIG REAL ESTATE

BOARD

TENNIS

(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.

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.

YES
NO
If YES, give details:
________________________________
________________________________
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: ____________________
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

43.

ADDRESS

TEL. NO.

JESSIE JOHN P. GIMENEZ

SALCEDO VILLAGE, MAKATI

845-1199

GINO BAUTISTA

ARNAIZ AVENUE, MAKATI

0917-8799258

RODINIL BUGAY

ARNAIZ AVENUE, MAKATI

0917-7016408

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.

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

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT

SIGNATURE (Sign inside the box)

ISSUED ON (mm/dd/yyyy)

06/02/2015
DATE ACCOMPLISHED

RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 4 of 4