CSC FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with check (/) and use separate sheet if necessary.

1. CS ID No.

I. PERSONAL INFORMATION

D
G
T

2. SURNAME
FIRST NAME
MIDDLE

A
R
O

Q
A
L

U
C
E

I
E
N

A G

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

17. RESIDENTIAL ADDRESS

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

5. PLACE OF BIRTH
6. SEX

Male

7. CIVIL STATUS

Single

Female

ZIP CODE

Widowed

Married

Separated

Annuled

Others, Specify

8. CITIZENSHIP

9. RELIGION

10. HEIGHT (m)

11. WEIGHT (kg)

12. BLOOD TYPE

_____

14. PAG-IBIG NO.

15. PHILHEALTH NO.

19-

16. SSS NO.

N/A

18. TELEPHONE NO.

N/A

19. PERMANENT ADDRESS

SAN MANUEL, AGLIPAY, QUIRINO

4
ZIP CODE

13. GSIS ID NO.

PALACIAN, AGLIPAY, QUIRINO

20. TELEPHONE NO.

gracedaquioag@yah

41

8 22. CELLPHONE NO. (if any)

6 23. AGENCY EMPLOYEE NO.

1 8-

8 1-

N/A

21 EMAIL ADDRESS (if any)

24. TIN

5
3

II. FAMILY BACKGROUND

25. SPOUSE'S SURNAME

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

RIYADH, SAUDI ARABIA

TELEPHONE NO.

N/A

27. FATHER'S SURNAME

ELMAR T. DAQUIOAG
ELISHA T. DAQUIOAG

FIRST NAME

MIDDLE NAME

28. MOTHER'S SURNAME

FIRST NAME

MIDDLE NAME

26. NAME OF CHILD (write full name and list all)

III. EDUCATIONAL BACKGROUND

INCLUSIVE DATES OF ATT

29. LEVEL

ELEMENTARY

NAME OF SCHOOL

(Write in full)

DEGREE/COURSE (Write in
full)

MARASAT PEQUENO

YEAR

HIGHEST GRADE/

GRADUATED

LEVEL/UNITS

(if graduated)

(if not graduated)

1992

GRADUATED

ELEMENTARY SCHOOL
SECONDARY

SAN MATEO VOCATIONAL

1996

& INDUSTRIAL HIGH SCHOOL

VOCATIONAL / TRADE COURSE

COLLEGE

SAINT MARY'S UNIVERSITY

GRADUATE STUDIES

NORTHEASTERN COLLEGE
NORTHEASTERN COLLEGE

2000
MASTER OF ARTS IN
EDUCATION
DOCTOR OF EDUCATION

2010
2012

GRADUATED

From

(to be filled up by CSC)

N (e.g. Jr., Sr.

AY, QUIRINO

LIPAY, QUIRINO

ioag@yahoo.com
9

3 1-

DATE OF BIRTH (mm/dd/yy)

11/6/2000
10/14/2002

DATES OF ATTENDANCE
To

SCHOLARSHIP / ACADEMIC
HONORS RECEIVED

IV. CIVIL SERVICE ELIGIBILITY

30. CAREER SERVICE/RA 1080 (BOARD/BAR) UNDER SPECIAL LAWS,
CES/CSEE

RATING

DATE OF EXAMINATION/
CONFERMENT

PLACE OF EXAMINATION/CONFERMENT

V. WORK EXPERIENCE (Include private employment; start from most recent experience)
31. INCLUSIVE DATES (mm/dd/yyyy)

Position Title
From

To

(Write in full)

DEPARTMENT/AGENCY/OFFICE/COMPANY

MONTHLY
SALARY

SALARY GRADE & STEP

INCREMENT

LICENSE (If applicable)

NUMBER

DATE OF RELEASE

STATUS OF
APPOINTMENT

GOV'T SEVICE
(Yes/No)

Page 2 of 4

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

32. NAME AND ADDRESS OF ORGANIZATION

(Write in full)

INCLUSIVE DATES (mm/dd/yyyy)

From

NUMBER OF HOURS

To

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

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

INCLUSIVE DATES (mm/dd/yyyy

From

NUMBER OF HOURS

To

VIII. OTHER INFORMATION

34. SPECIAL SKILLS/HOBBIES

35. NON-ACADEMIC DISTINCTIONS/RECOGNITION

ZATION
POSITION/NATURE OF WORK

CONDUCTED/SPONSORED BY

(Write in full)

36. MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

Page 3 of 4

37. Are you related by consanguinity or affinity to any of the following:

a. Within the third degree (for National Government employess):
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)

Appointing authority or recommending authority where you will appointed?

38. a. Have you ever been formally charged?

b. Have you ever been guilty of administrative offense?

39. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or tribunal?

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

41. Have you ever been a candidate in a national or local election (except barangay election)?

42. Pursuant to: (a)Indigenous People's Act (RA 8371); (b) Magna Carta for Disables Persons (RA 7277); and Solo Parents Welfare
Act of 2000 (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?

43. REFERENCES (persons not related by consanguinity or affinity to applicant/ appointee)

NAME

ADDRESS

TELEPHONE NO.

44. 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 pertinen

I also authorize the agency/authorized representative to verify/validate the contents stated herein. I trust that this information shall
remain confidential.

COMMUNITY TAX CERTIFICATE NO.

SIGNATURE

ISSUED AT
ISSUED ON

DATE ACCOMPLISHED

//
/

YES

NO

IF YES, give details:

_______________________________________________________
_______________________________________________________
________________________
YES

NO

IF YES, give details:

_______________________________________________________
___________________________________
YES

NO

IF YES, give details:

_______________________________________________________
_______________________________________________________
________________________
YES
NO
IF YES, give details:
_______________________________________________________
________________________________________
YES

NO

IF YES, give details:

_______________________________________________________
________________________________________
YES
NO
IF YES, give details:
_______________________________________________________
__________________________________
YES

NO

IF YES, give details:

_______________________________________________________
_______________________________________

YES

NO

IF YES, give details:

_______________________________________________________
_____________________________________________
YES

NO

IF YES, give details:

_______________________________________________________
_______________________________________
YES

NO

IF YES, give details:

_______________________________________________________
_________________________________________

ID taken within the last 6 months

3.5 cm. X 4.5 cm

Computer generated or xerox copy of

picture is not acceptable

PHOTO

RIGHT THUMBMARK
Page 4 of 4

CSC FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with check (/) and use separate sheet if necessary.

1. CS ID No.

I. PERSONAL INFORMATION

G
C
D

2. SURNAME
FIRST NAME
MIDDLE

O
L
U

H
A
L

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

A
R
N

N
I
U

G
E
A

05/

5. PLACE OF BIRTH

N A
S J
N
03/

Y
3. NAME EXTENSION (e.g. Jr., Sr.
17. RESIDENTIAL ADDRESS

1989

DUNGO, AGLIPAY, QUIRINO

6. SEX

Male

Female

7. CIVIL STATUS

Single

Widowed

Married

Separated

Annuled

Others, Specify

8. CITIZENSHIP

FILIPINO

9. RELIGION

EVANGELICAL

10. HEIGHT (m)

SAN MANUEL, AGLIPAY, QUIRINO

ZIP CODE

_____

3403

18. TELEPHONE NO.

N/A

19. PERMANENT ADDRESS

SAN MANUEL, AGLIPAY, QUIRINO

152

11. WEIGHT (kg)

53

ZIP CODE

3403

12. BLOOD TYPE

B+

20. TELEPHONE NO.

N/A

13. GSIS ID NO.

N/A

21. E-MAIL ADDRESS (if any)

gohangnaclariesjoy@yahoo.com

14. PAG-IBIG NO.

N/A

22. CELLPHONE NO. (if any)

15. PHILHEALTH NO.

N/A

23. AGENCY EMPLOYEE NO.

N/A

16. SSS NO.

N/A

24. TIN

464-593-162-000

o9361490439

II. FAMILY BACKGROUND

25. SPOUSE'S SURNAME

26. NAME OF CHILD (write full name and list all)

FIRST NAME

N/A

MIDDLE NAME

N/A

OCCUPATION

N/A

EMPLOYER/BUS. NAME

N/A

BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

27. FATHER'S SURNAME

GOHANGNA

FIRST NAME

JUAN

MIDDLE NAME

DULNUAN

28. MOTHER'S SURNAME

DATE OF B

6/6/1962

DULNUAN

FIRST NAME

DAISY

MIDDLE NAME

BALAJO

12/12/1967

III. EDUCATIONAL BACKGROUND

29. LEVEL

NAME OF SCHOOL

(Write in full)

DEGREE/COURSE (Write in
full)

YEAR

HIGHEST GRADE/

GRADUATED

LEVEL/UNITS

(if graduated)

(if not graduated)

INCLUSIVE DATES OF ATTENDANCE

SCHOLARSH
From

To

ELEMENTARY

OSMENA ELEMENTARY SCHOOL

2000

1999

2000

SECONDARY

BALLIGUI HIGH SCHOOL

2005

2000

2005

QUIRINO STATE COLLEGE

2012

2008

2012

VOCATIONAL / TRADE
COURSE

COLLEGE

GRADUATE STUDIES

(to be filled up by CSC)

DATE OF BIRTH (mm/dd/yy)

SCHOLARSHIP / ACADEMIC HONORS RECEIVED

LGU

IV. CIVIL SERVICE ELIGIBILITY

30. CAREER SERVICE/RA 1080 (BOARD/BAR) UNDER SPECIAL LAWS,

CES/CSEE

LICENSURE EXAMINATION FOR TEACHERS

RATING

DATE OF EXAMINATION/
CONFERMENT

PLACE OF EXAMINATION/CONFERMENT

75.60

11/27/17

BAGUIO CITY

V. WORK EXPERIENCE (Include private employment; start from most recent experience)
31. INCLUSIVE DATES (mm/dd/yyyy)

Position Title
From

To

6/3/2013

PRESENT

(Write in full)

LOCAL SCHOOL BOARD

DEPARTMENT/AGENCY/OFFICE/COMPANY

DEPARTMENT OF EDUCATION

MONTHLY SALARY

SALARY GRADE & STEP INCREMENT

LICENSE (If applicable)

NUMBER

DATE OF RELEASE

1156614

12/13/2012

STATUS OF APPOINTMENT

GOV'T SEVICE (Yes/No)

Page 2 of 4

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

32. NAME AND ADDRESS OF ORGANIZATION

(Write in full)

CHILD EVANGELISM MINISTRY

NUMBER OF HOURS

INCLUSIVE DATES (mm/dd/yyyy)

From

To

2008

PRESENT

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

INCLUSIVE DATES (mm/dd/yyyy

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

NUMBER OF HOURS

From

To

DIVISION TRAINING ON INTERNET AND COMPUTING FUNDAMENTALS

4/4/2015

4/13/2015

80

INTERNET AND COMPUTING FUNDAMENTALS (ICF)

4/4/2015

4/13/2015

80

VIII. OTHER INFORMATION

34. SPECIAL SKILLS/HOBBIES

ENCODING

35. NON-ACADEMIC DISTINCTIONS/RECOGNITION

POSITION/NATURE OF WORK

TRAINOR/EVALUATOR

CONDUCTED/SPONSORED BY

(Write in full)

DIVISION OFFICE OF QUIRINO

TECHNICAL EDUCATION AND SKILLS DEVELOPMENT

AUTHORITY

36. MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

Page 3 of 4

37. Are you related by consanguinity or affinity to any of the following:

a. Within the third degree (for National Government employess):
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)

Appointing authority or recommending authority where you will appointed?

38. a. Have you ever been formally charged?

b. Have you ever been guilty of administrative offense?

39. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or tribunal?

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

41. Have you ever been a candidate in a national or local election (except barangay election)?

42. Pursuant to: (a)Indigenous People's Act (RA 8371); (b) Magna Carta for Disables Persons (RA 7277); and Solo Parents Welfare Act of 2000 (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?

43. REFERENCES (persons not related by consanguinity or affinity to applicant/ appointee)

NAME

ADDRESS

GRACE T. DAQUIOAG

PALACIAN, AGLIPAY,QUI.

GERRY C. LUNAG

SAN MANUEL, AGL. QUI.

TELEPHONE NO.

44. 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.

8347720
COMMUNITY TAX CERTIFICATE NO.
SAN MANUEL, AGLIPAY, QUIRINO

SIGNATURE

ISSUED AT

1/7/2016

MARCH 07, 2016

ISSUED ON

DATE ACCOMPLISHED

///
YES

NO

IF YES, give details:

___________________________________________________________
___________________________________________________________
________________
YES

NO

IF YES, give details:

___________________________________________________________
_______________________________
YES

NO

IF YES, give details:

___________________________________________________________
___________________________________________________________
________________
YES
NO
IF YES, give details:
___________________________________________________________
____________________________________
YES

NO

IF YES, give details:

___________________________________________________________
____________________________________
YES
NO
IF YES, give details:
___________________________________________________________
______________________________
YES

NO

IF YES, give details:

___________________________________________________________
___________________________________

YES

NO

IF YES, give details:

___________________________________________________________
_________________________________________
YES

NO

IF YES, give details:

___________________________________________________________
___________________________________
YES

NO

IF YES, give details:

___________________________________________________________
_____________________________________

ID taken within the last 6 months

3.5 cm. X 4.5 cm

Computer generated or xerox copy of

picture is not acceptable

PHOTO

RIGHT THUMBMARK

Page 4 of 4