CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. 1. CS ID No. (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 6. SEX 7. CIVIL STATUS

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A S U N C I O N
06
Male Female

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

N/A

18

1979

16. RESIDENTIAL ADDRESS

SAN NICOLAS, ILOCOS NORTE

Single Married Annulled Widowed Separated Others, specify_______
17. TELEPHONE NO. 18. PERMANENT ADDRESS ZIP CODE

DOOR #7, 5-DOOR APARTMENT, MMSU HOUSING, BRGY. QUILING SUR, CITY OF BATAC
2906 N/A DOOR #7, 5-DOOR APARTMENT, MMSU HOUSING, BRGY. QUILING SUR, CITY OF BATAC

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.

FILIPINA

1.76 120 B B79LJAAB019 N/A 05-000054244-7 N/A

BERMUDEZ MILAGROS GAMIAO TEACHING MARIANO MARCOS STATE UNIVERSITY CITY OF BATAC, ILOCOS NORTE
(Continue on separate sheet if necessary) 19. TELEPHONE NO. 20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO. (if any) 22. AGENCY EMPLOYEE NO. 23. TIN ZIP CODE

2906 N/A
AABARRUGA323@YAHOO.COM

09289379278 IP-0640 923-946-073

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

ABIJAH MCGUILLER ADAH MIKAELA AZIEL MAGDALAINE

06 11 03

/ / / / / / / / / / / / /

15 22 04

/ / / / / / / / / / / / /

2003 2004 2011

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

BARRUGA MOISES PACLEB ASUNCION BARRUGA SUSANA ASUNCION

YEAR GRADUATED (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28. LEVEL NAME OF SCHOOL (Write in full) DEGREE COURSE full) (Write in HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated) INCLUSIVE DATES OF ATTENDANCE From To SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

(if graduated)

ELEMENTARY

SAN NICOLAS ELEMENTARY SCHOOL SAN NICOLAS NATIONAL HIGH SCHOOL

ELEMENTARY SECONDARY N/A

BACHELOR OF SCIENCE IN COMPUTER SCIENCE

1992 1996 N/A 2000 N/A N/A

N/A N/A N/A N/A N/A 6

1986 1992 N/A 1996 N/A 2001

1992 1996 N/A 2000 N/A

2002

WITH DISTINCTION
3rd HONORABLE MENTION

SECONDARY VOCATIONAL / TRADE COURSE COLLEGE

N/A
MARIANO MARCOS STATE UNIVERSITY

N/A N/A N/A N/A

N/A
GRADUATE STUDIES

N/A
MASTER OF ARTS IN EDUCATION

MARIANO MARCOS STATE UNIVERSITY

(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 RATING DATE OF EXAMINATION / CONFERMENT LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE
0000-00-00 0000-00-00

EDP-PROFICIENCY EXAM-PROGRAMMING

84.90 83.24

11 / 10 / 2001 06 / 18 / 2000 / / / / / / / / / /

QUEZON CITY LAOAG CITY

N/A N/A

CAREER SERVICE PROFESSIONAL

(Continue on separate sheet if necessary)

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

STATUS OF APPOINTMENT

GOV'T SERVICE (Yes / No)

10 / 01 / 2010 PRESENT / / 06 / 24 / 2010 09 / 30 / 2010 07 / 01 / 2009 06 / 23 / 2010 07 / 01 / 2008 06 / 30 / 2009 07 / 01 / 2007 06 / 30 / 2008 03 / 01 / 2007 06 / 30 / 2007 03 / 01 / 2004 02 / 28 / 2007

COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 17540 COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 15900 COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 14483 COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 13066 COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 11878 COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 10798 COMPUTER PROGRAMMER I MARIANO MARCOS STATE UNIVERSITY 10535
SCIENCE RESEARCH

11-2 11-2 11-2 11-2 11-2 11-2 11-1 09-1

PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT PERMANENT TEMPORARY

CONTRACT OF SERVICE CONTRACT OF SERVICE CONTRACT OF SERVICE CONTRACT OF SERVICE

YES YES YES YES YES YES YES YES NO NO NO NO YES

06 / 03 / 2003 02 / 29 / 2004 ASSISTANT 04 / 01 / 2003 06 / 02 / 2003 01 / 06 / 2003 03 / 31 / 2003 11 / 04 / 2002 12 / 31 / 2002 06 / 01 / 2002 10 / 31 / 2002 07 / 17 / 2001 03 / 31 / 2002
/ / / / / / / / / / / / / / / / / / / / / / / / / / / /

MARIANO MARCOS STATE UNIVERSITY 9318

CLERK I INSTRUCTOR I INSTRUCTOR I INSTRUCTOR I INSTRUCTOR I

MARIANO MARCOS STATE UNIVERSITY 274.50/d -MARIANO MARCOS STATE UNIVERSITY 11167 MARIANO MARCOS STATE UNIVERSITY 11167 MARIANO MARCOS STATE UNIVERSITY 11167 MARIANO MARCOS STATE UNIVERSITY 11733
12-1 12-1 12-1 12-3

SUBSTITUTE

(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 (Write in full) INCLUSIVE DATES (mm/dd/yyyy) From / / / / / / / / / / / / / / / To / / / / / NUMBER OF HOURS POSITION / NATURE OF WORK

(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 To NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full)
REGIONAL INFORMATION TECHNOLOGY AND ELECTRONIC COMMERCE COMMITTEE

WEB CONTENT MANANGEMENT USING MAMBO/JOOMLA

TRAINORS TRAINING PROGRAM FOR SMALL-MEDIUM-ENTERPRISE BUSINESS CENTER IT ADMINISTRATORS

04 / 20 / 2005 09 / 20 / 2004 05 / 31 / 2004

/ / / / / / / / / / / / / / / / / / / / / / / /

04 / 21 / 2005 09 / 24 / 2004 06 / 01 / 2004

/ / / / / / / / / / / / / / / / / / / / / / / /

16 40 16

DEVELOPMENT BANK OF THE PHILIPPINES

ADVANCED PHP PROGRAMMING WITH MYSQL DATABASE

REGIONAL INFORMATION TECHNOLOGY AND ELECTRONIC COMMERCE COMMITTEE

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

DRIVING COMPUTER TROUBLESHOOTING

TAKUAT AWARD

ASSOCIATION OF NON-TEACHING ADMINISTRATIVE PERSONNEL (ANTAP) PHILIPPINE SOCIETY OF INFORMATION TECHNOLOGY EDUCATORS

(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.

YES NO If YES, give details:

37

a. Have you ever been formally charged?

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

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

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?

If YES, give details: ________________________________ ________________________________

YES NO If YES, give details: ________________________________ ________________________________

40.

Have you ever been a candidate in a national or local election (except Barangay election)?

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 ADDRESS TEL. NO.

AGUSTIN, EPIFANIA O. VILLACILLO, REYNOLD P. ESTEBAN, EDMUND EDISON A.

43.

BATAC, ILOCOS NORTE BATAC, ILOCOS NORTE BATAC, ILOCOS NORTE

792-3131 792-2584 792-2584

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.

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)

DATE ACCOMPLISHED

RIGHT THUMBMARK

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