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CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes with check ( ) and use separate sheet if necessary 1. CS ID No. (to be filled up by CSC)

I.PERSONAL INFORMATION

2. SURNAME
N A V A L T A
FIRST NAME
A N T O N I O
MIDDLE NAME
F O N A C I E R 3. NAME EXTENSION (e.g. Jr.,, Sr. N/A
4. DATE OF BIRTH (mm/dd/yyyy) 10/25/1965 16. RESIDENTIAL
5. PLACE OF BIRTH ADDRESS Camp Bado Dangwa, La Trinidad, Benguet
Dalayap, Langiden, Abra
6. SEX Male Female

7. CIVIL STATUS ZIP CODE 2601


Single
17. TELEPHONE NO.
(074) 422-55-15

18. PERMANENT Dalayap, Langiden, Abra


ADDRESS
8. CITIZENSHIP Filipino
9. HEIGHT (m) 1.62
10. WEIGHT (kg) 60 2807
ZIP
CODE
11. BLOOD TYPE B N/A
19. TELEPHONE NO
20. E-MAIL ADDRESS (if
12. GSIS POLICY NO. N/A any) N/A
21. CELLPHONE NO. (if
13. PAG-IBIG NO. 1290-0036-65-16 any) 09175384459
22. AGENCY EMPLOYEE
14. PHILHEALTH NO. 04-000040543-6 NO. N/A
15. SSS NO. N/A 23. TIN 154-637-291
II. FAMILY BACKGROUND

24. SPOUSES SURNAME 25. NAME OF CHILD (Write full name and list
N/A all)
DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME
N/A Ysrael Anthony B Castillo 10/25/2002
MIDDLE NAME N/A Denmark Anthony C Navalta 07/07/2006
OCCUPATION
N/A
EMPLOYER/BUS
NAME N/A
BUSINESS ADDRESS
N/A
TELEPHONE NO.
N/A
26. FATHERS SURNAME
Navalta 05/16/1928
FIRST NAME
Honorato
MIDDLE NAME
Papagayo
27. MOTHERS MAIDEN NAME

SURNAME Fonacier 09/17/1930


FIRST NAME Josefa
MIDDLE NAME Ricafort
III. EDUCATIONAL BACKGROUND

28. HIGHEST INCLUSIVE DATES


YEAR SCHOLARSHIP/
LEVEL GRADE/ LEVEL/ OF
NAME OF SCHOOL DEGREE/COURSE GRADUATED ACADEMIC
UNITS EARNED ATTENDANCE
(Write in full) (Write in full) (if HONORS
(if not
graduated) From To RECEIVED
graduated)

ELEMENTARY Langiden Central School N/A 1977 1971 1977 N/A

St. Mary High School N/A 1981 1977 1981


SECONDARY N/A
VOCATIONAL/
N/A N/A N/A N/A N/A N/A
TRADE COURSE N/A
Abra State Institute of Bachelor of
COLLEGE Sciences and Secondary 1990 1984 1990
N/A
Technology Education

GRADUATE
STUDIES N/A N/A N/A N/A N/A N/A N/A

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IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/RA 1080 (BOARD/Bar) DATE OF LICENSE (if applicable)


UNDER SPECIAL LAWS.CES/CSEE RATING EXAMINATION/ PLACE OF EXAMINATION/ CONFERMENT NUMBER DATE OF
CONFERMENT RELEASE

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


V. WORK EXPERIENCE (include private employment, Start from most recent work experience)

30. INCLUSIVE DATES SALARY


(mm/dd/yyyy) POSITION TITLE DEPARTMENT/AGENCY/OFFICE/CO MONTHLY SALARY GRADE & STATUS OF GOVT
(Write in full) MPANY STEP APPOIN SERVICE
From To INCREMEN MENT (Yes/No)
T

01/26/2011 Present Mobility PNCO RLRDD, PRO Cordillera P 25,394.00 18 Permane Yes
nt
04/18/2005 04/19/2005 Operations ROPD, PRO Cordillera P 16,552.00 17 Permane Yes
PNCO nt
09/21/2002 04/17/2005 Operations Langiden MPS, Abra P 12,375.00 16-2 Permane Yes
PNCO PPO nt
09/20/2002 05/29/2005 Operations PHQ, Abra PPO P 10,875.00 14-2 Permane Yes
PNCO nt
07/15/1994 05/28/2002 Plans PNCO ROPD, PRO Cordillera P 8,758.00 12-1 Permane Yes
nt
04/11/1992 07/14/1994 Rifleman RMG, PRO Cordillera P 1,800.00 10-1 Permane Yes
nt
09/16/1991 04/10/1992 Police Trainee PNP Training Command P 1,000.00 10-1 Permane Yes
nt
/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

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

31. INCLUSIVE DATES


NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy) NUMBER OF POSITION/NATURE OF WORK
(Write in full) From To HOURS

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


/ / / /

/ / / /

/ / / /

/ / / /

VII TRAINING PROGRAMS (Start from the most recent training)

32. INCLUSIVE DATES (mm/dd/yyyy)


TITLE OF SEMINAR/CONFERENCE/WORKSHOP NUMBER OF CONDUCTED/SPONSORED BY
(Write in full) From To HOU (Write in full)
RS
Police Basic Course 09/16/1991 03/09/1992 800 PNP Training Command
PNP Special Counter Operations Unit 11/03/1993 12/18/1993 200 PNP Special Action Force
Criminal Investigation and Detection 01/20/1977 06/20/1977 800 Regional Training School - CAR
course
Public Safety Junior Leaderships Course 05/04/2001 09/29/2001 400 Regional Training School - CAR
Public Safety Senior Leadership Course 10/15/2009 01/30 2010 560 Regional Training School 1

VIII. OTHER INFORMATION

33. 34. NON-ACADEMIC DISTINCTIONS/RECOGNITION 35. MEMBERSHIP/


SPECIAL SKILLS/HOBBIES (Write in full) ASSOCIATION/ORGANIZATION
(Write in full)
Basic Computer Operation Medalya Kagalingan 8 N/A

Medalya ng Kasanayan - 13

Medalya ng Papuri - 17

Medalya ng Mabuting Asal - 4

Medalya ng Pakikipaglaban sa
Manliligalig - 3

Medalya ng Pagtulong sa Nasalanta 1

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

a. Within the third degree (for National Government Employees): YES NO


Appointing authority, recommending authority, chief of office/bureau/department or If YES, give details:
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): YES NO


Appointing authority or recommending authority where you will be appointed? If YES, give details:

37. a. Have you ever been formally charged?


YES NO
If YES, give details:

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


YES NO
If YES, give details:

38. Have you ever been convicted of any crime or violation of any law, decree, ordinance YES NO
or regulations by any court or tribunal? If YES, give details:

39. Have you ever been forced to retired/resign or dropped from employment in the public YES NO
or private sector? If YES, give details:

40. Have you ever been a candidate in a national or local election (except Barangay YES NO
election)? If YES, give details:

41. Pursuant to: (a) Indigenous Peoples Act (RA 8371); (b) Magna Carta for Disabled
Persons (RA 7277); and (c) Solo Parents Welfare Act of 2000 (8972)*; please answer the
following items:
YES NO
a. Are you a member of any indigenous group? If YES, give details: Tingguian

YES NO
b. Are you differently abled? If YES, give details:

YES NO
c. Are you a solo parent?
If YES, give details:

42. REFERENCES (Person not related by consanguinity or affinity to applicant/appointee)

NAME ADDRESS TELEPHONE NO.


PSSUPT DAVID Q LACDAN Camp Bado Dangwa, La Trinidad, Benguet 422-5435
ID picture taken within
PSSUPT DONATO O BACQUIAN Camp Bado Dangwa, La Trinidad, Benguet 422-5435 The last 6 months
PSUPT REGUEL B SNTAMARIA Camp Bado Dangwa, La Trinidad, Benguet 422-5435 3.5 cm. X 4.5 cm

42. 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. Computer generated
Or Xerox copy of picture
I also authorize the agency/authorized representative to verify/validate the contents stated herein. I trust that this information shall Is not acceptable
remain confidential.
PHOTO

06455818

COMMUNITY TAX CERTIFICATE NO.

LA TRINIDAD, BENGUET

ISSUED AT SIGNATURE

11/13/2013 12/02/2013

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED


RIGHT THUMBMARK

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