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CS Form No. 212 Attachment - Work Experience Sheet
CS Form No. 212 Attachment - Work Experience Sheet
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME PINEDA
NAME EXTENSION (JR., SR
FIRST NAME MANOLET
Other/s:
Subdivision/Village Ba
6700 CATBALOGAN CITY SA
7. HEIGHT (m) 5'8
City/Municipality Pr
8. WEIGHT (kg) 70 ZIP CODE
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) manoletpineda2018@gmail.c
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME N/A
OCCUPATION N/A
SURNAME PINEDA
SECONDARY /
VOCATIONAL SAMAR NATIONAL SCHOOL SECONDARY
N/A N/A
TRADE
COURSE
COLLEGE SAMAR STATE UNIVERSITY BACHELOR OF ELEMENTARY EDUCATION
SIGNATURE DATE
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person
Dual Citizenship
by naturalization
Street
Barangay
SAMAR
Province
Street
Barangay
SAMAR
Province
N/A
09755086135
manoletpineda2018@gmail.com
SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
2010
2014
N/A
2018
12/4/2018 PRESENT ADMINISTRATIVE CLERK SAMAR PROVINCIAL HOSPITAL 5000.00 JOB ORDER
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM 212 (Revised 20
LICENSE (if applicable)
Date of
Validity
GOV'T
SERVICE
(Y/
N)
N/A
arate sheet if necessary)
COMPUTER LITERATE
MENTORING
SELF-MOTIVATED
SELF-MANAGEMENT
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation
YES ✘ NO
by any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):
40. 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? YES ✘ NO
If YES, please specify:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:
ID/License/Passport No.:
Signature (Sign inside the box)
Date/Place of Issuance:
Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.