CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

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

I. PERSONAL INFORMATION
2. SURNAME N| U | Ñ | E | Z | | | | | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME K |A |R |E |N | | | | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME P| A | V | A | | | | | | | | | | | | | | | | | | | | 3. |NAME

| EXTENSION
| | | (e.g.| Jr., |Sr.) |

4. DATE OF BIRTH (mm/dd/yyyy) 01 / 18 / 1998 16. RESIDENTIAL ADDRESS

5. PLACE OF BIRTH SAN MATEO, RIZAL ZONE 4, LOHO, LAGONOY, CAMARINES SUR

6. SEX q Male q
✔ Fem ale
7. CIVIL STATUS ✔ Single
q qWidowed ZIP CODE 4425
qMarried q Separated 17. TELEPHONE NO. N. A
qAnnulled qOthers, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP ZONE 4, LOHO, LAGONOY, CAMARINES SUR

FILIPINO
9. HEIGHT (m) 165cm.

10. WEIGHT (kg) 42 kg. ZIP CODE 4425

11. BLOOD TYPE O 19. TELEPHONE NO. N. A

12. GSIS ID NO. N. A 20. E-MAIL ADDRESS (if any) nunezkaren757@gmail.com
13. PAG-IBIG ID NO. 121248436192 21. CELLPHONE NO. (if any) +639484947461/+639154686391
14. PHILHEALTH NO. 1002-5356-5297 22. AGENCY EMPLOYEE NO. N. A

15. SSS NO. 05-1511598-5 23. TIN N. A

II. FAMILY BACKGROUND

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

FIRST NAME N. A N. A / /

MIDDLE NAME N. A / /

OCCUPATION N. A / /

EMPLOYER/BUS. NAME N. A / /

BUSINESS ADDRESS N. A / /

TELEPHONE NO. N. A / /

(Continue on separate sheet if necessary) / /

26. FATHER'S SURNAME NUÑEZ 04 / 10 / 1965

FIRST NAME NESTOR / /

MIDDLE NAME RELLOSO / /

27. MOTHER'S MAIDEN NAME 09 / 30 / 1970

SURNAME PAVA / /

FIRST NAME MA. DIVINA / /

MIDDLE NAME EBRO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Grade 1-6 2011 91 2006 3rd Honorable

LOHO ELEMENTARY SCHOOL 2011 Mention
SAN RAMON PILOT NATIONAL HIGH 1st Yr. -4th Yr. 2015 92 2011 Conduct Award
SECONDARY 2015
SCHOOL
VOCATIONAL /
TRADE COURSE
COLLEGE
PARTIDO STATE UNIVERSITY 1st yr. -4th yr. 2019 1.1 2015 2019 N. A

GRADUATE STUDIES

(Continue on separate sheet if necessary)

Page 1 of 4