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 GUIAOAN

FIRST NAME NYMPHA

MIDDLE NAME BANDIWAN 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 06/24/1985 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH TINOC, IFUGAO AP-APID, TINOC, IFUGAO

6. SEX Male Female
7. CIVIL STATUS 3609
Single Widowed ZIP CODE

Married Separated 17. TELEPHONE NO. NONE

Annulled Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP FILIPINO AP-APID, TINOC, IFUGAO

9. HEIGHT (m) 1.51
10. WEIGHT (kg) 55 ZIP CODE 3609
11. BLOOD TYPE AB 19. TELEPHONE NO. NONE
12. GSIS ID NO. 20. E-MAIL ADDRESS (if any) amir11aidan14@gmail.com
13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any) 09063851139
14. PHILHEALTH NO. 04-000044950-6 22. AGENCY EMPLOYEE NO. 4458100
15. SSS NO. NONE 23. TIN 407-897-021-000
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME GUIAOAN 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME WINIFREDO AMIR KANIEL B. GUIAOAN 03/08/2011

MIDDLE NAME GUIAOAN AIDAN KEITH B. GUIAOAN 10/28/2014
OCCUPATION PROJECT DEVELOPMENT OFFICER II
EMPLOYER/BUS. NAME DSWD-CAR
BUSINESS ADDRESS BAGUIO CITY
TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME BANDIWAN

FIRST NAME JACK

MIDDLE NAME BALDIC

27. MOTHER'S MAIDEN NAME

SURNAME PINKIHAN

FIRST NAME BELINA

MIDDLE NAME MARTIN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR

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

(if graduated)
ELEMENTARY TINOC CENTRAL SCHOOL 1998 1992 1998 FOURTH HONORS

SECONDARY TINOC NATIONAL HIGH SCHOOL 2002 1998 2002 VALEDICTORIAN

VOCATIONAL /

N/A
TRADE
COLLEGE
COURSE BS
UNIVERSITY OF THE CORDILLERAS 2007 2002 2007 NONE
ACCOUNTANCY
GRADUATE STUDIES
N/A

(Continue on separate sheet if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE
CAREER SERVICE PROFESSIONAL BAGUIO CITY NATIONAL HIGH SCHOOL,
80.84% 03/09/2008
EXAMINATION GOVERNOR PACK ROAD, BAGUIO CITY

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
01/01/2017 DATE ADMIN. ASSISTANT III TINOC NATIONAL HIGH SCHOOL 17,142.00 09-2 PERMANENT YES

01/01/2016 12/31/2016 ADMIN. ASSISTANT III TINOC NATIONAL HIGH SCHOOL 16,671.00 09-2 PERMANENT YES

04/01/2014 12/31/2015 ADMIN. ASSISTANT III TINOC NATIONAL HIGH SCHOOL 16,212.00 09-2 PERMANENT YES

06/01/2012 03/31/2014 ADMIN. ASSISTANT III TINOC NATIONAL HIGH SCHOOL 16,050.00 09-1 PERMANENT YES

04/01/2011 05/31/2012 ADMIN. ASSISTANT III TINOC NATIONAL HIGH SCHOOL 09-1 PROBATIONARY YES

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

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /
(Continue on separate sheet if necessary)

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

INCLUSIVE DATES OF ATTENDANCE
32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write NUMBER OF CONDUCTED/ SPONSORED BY
in full) (mm/dd/yyyy) HOURS (Write in full)
From To
ORIENTATION-WORKSHOP ON THE IMPLEMENTATION OF THE
03/17/2016 03/18/2016 16 DEPED, DIVISION OFFICE
NEW GOVERNMENT ACCOUNTING MANUAL

LEADERSHIP AND VALUES RE-ORIENTATION 12/17/2013 12/18/2013 16 CAR COOPERATIVE UNION

INTERNAL CONTROL 10/04/2013 10/05/2013 16 CAR COOPERATIVE UNION

BASIC COMPUTER LITERACY TRAINING 05/01/2013 05/11/2013 80 DEPED, TESDA

OPEN SOURCE APPLICATION SOFTWARE 10/21/2012 10/26/2012 40 BENGUET STATE UNIVERSITY

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

(Continue on separate sheet if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4
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 If YES, give details:
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 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 CONTACT NO.

FERNANDO D. MADIANO POBLACION, TINOC, IFUGAO 9069509283 ID picture taken within

the last 6 months
FABIOLA L. DAMULLOG POBLACION, TINOC, IFUGAO 9067553756 3.5 cm. X 4.5 cm
(passport size)
LORENZO BINWIHAN AP-APID, TINOC, IFUGAO 9354537034
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
is not acceptable
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

30291760
COMMUNITY TAX CERTIFICATE NO.

Ap-apid, Tinoc, Ifugao

ISSUED AT SIGNATURE (Sign inside the box)

01/26/2017
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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