CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15121129

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 LONGOS
FIRST NAME JHONALYN
MIDDLE NAME TIZON 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS P-1 CABUNGAAN, CAGDIANAO, DINAGAT ISLANDS

4. DATE OF BIRTH (mm/dd/yyyy) 06 / 23 / 1993
5. PLACE OF BIRTH Lagundi, Aurora Surigao City
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 8411
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS P-1 CABUNGAAN, CAGDIANAO, DINAGAT ISLANDS

8. CITIZENDSHIP Filipino
9. HEIGHT (m) 152
10. WEIGHT (kg) 50 ZIP CODE 8411
11. BLOOD TYPE A+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) kemerald779@gmail.com

13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any) 09977106601
14. PHILHEALTH NO. 180252314537 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME longos 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME jade emerald kin Temistocles II T. Longos 12 / 21 / 2014

MIDDLE NAME ecoben

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Tizon

FIRST NAME Roberto

MIDDLE NAME Petallar

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Toren

FIRST NAME Alma

MIDDLE NAME Ellar

III. EDUCATIONAL BACKGROUND

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

CABUNGAAN ELEMENTARY 2000-06- 2006-03-

ELEMENTARY 2006 2nd honors
SCHOOL 05 31

CAGDIANAO NATIONAL 2006-06- 2010-03- 1ST HONORABLE

SECONDARY 2010
HIGH SCHOOL 05 31 MENTION

VOCATIONAL/ TRADE
COURSE

BACHELOR OF
SURIGAO STATE COLLEGE 2010-06- 2015-03-
COLLEGE SECONDARY 2015
OF TECHNOLOGY 07 31
EDUCATION
SURIGAO STATE COLLEGE
GRADUATE STUDIES MAED 9
OF TECHNOLOGY

IV. CIVIL SERVICE ELIGIBILITY

LONGOS, JHONALYN TIZON - T15121129 CS FORM 212 (Revised 2005), Page 1 of 3
29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE
LET (LICENSURE EXAMINATION FOR
77 09 / 27 / 2015 CAGAYAN DE ORO CITY 1426147 01/26/2016
TEACHER)

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

06/08/2017 2018-16-02 Teacher 1 Deped 20000 0-0 Permanent No

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

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

VALENCIA NATIONAL HIGH SCHOOL 2016-8-9 2016-1- 5 MON TEACHET

VALENCIA NATIONAL HIGH SCHOOL 2016-8-9 2016-1- 5MON TEACHER

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

32. INCLUSIVE DATES OF
ATTENDANCE
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
(Write in full) HOURS (Write in full)
From To

TRAINING-WORKSHOP ON LOCALUZATION AND

CONTEXTUALIZATION OF KEARNING MATERIALS FOR SECONDARY 10 / 27 / 2016 10 / 29 / 2016 3 DAY
TEACHERS

DISTRICT TRAINING ON SPECIFIC LEARNING DISABILITIES

10 / 24 / 2016 10 / 26 / 2016 3 DAY LYDIA B. ELUDO
THROUGH INCLUSIVE EDUCATION

STUDENT CONGRESS 12 / 17 / 2014 12 / 17 / 2014 12hrs

MANUNUYAT: SURIGAONON
INTERNATIONAL SYMPOSIUM ON LANGUAGE PRESERVATION AND WRITING IN SURIGAONON
08 / 04 / 2014 08 / 05 / 2014 24hrs
PROMOTION ATTY. CHARLO D PAREDES,
FRANCISCO P. DUMANIG,PHD

ICT LITERACY 08 / 28 / 2013 10 / 12 / 2013 10dys

UNITED STATES AGENCY

JOB ENABLING ENGLISH PROFICIENCY 06 / 04 / 2013 07 / 05 / 2013 58hrs INTERNATIONAL
DEVELOPMENT

VIII. OTHER INFORMATION

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

LONGOS, JHONALYN TIZON - T15121129 CS FORM 212 (Revised 2005), Page 2 of 3

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 person who
has immediate supervision over you in the Office, Bureau or Department where you will be If YES, give details:
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 or YES NO
regulation by any court or tribunal?
If YES, give details:
_____________________________________
_____________________________________

39. 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, AWOL
or phased out, in the public or private sector? If YES, give details:
_____________________________________
_____________________________________

40. 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? YES NO

If YES, please specify:_______________________
b. Are you differently abled? YES NO
If YES, please specify:_______________________
c. Are you a solo parent? YES NO
If YES, please specify:_______________________

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

NAME ADDRESS TEL. NO.

X
43. 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. PHOTO

02697092

COMMUNITY TAX CERTIFICATE NO.

Dinagat islands

ISSUED AT SIGNATURE (Sign inside the box)

2018-02-07 02 / 16 / 2018

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

LONGOS, JHONALYN TIZON - T15121129 CS FORM 212 (Revised 2005), Page 3 of 3