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CS Form No. 212 Revised Personal Data Sheet - New
CS Form No. 212 Revised Personal Data Sheet - New
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME PITOGO
NAME EXTENSION (JR., SR
FIRST NAME VILMOR
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) OGOTIPROMLIV@GMAIL.COM
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A
OCCUPATION N/A
SURNAME ACIBO
TRADE
COURSE
COLLEGE NORTHWEST SAMAR STATE UNIVERSITY BS IN CRIMINOLOGY 2008 2012
GRADUATE STUDIES
SIGNATURE DATE
CS FORM 212 (Revised 2017
L DATA SHEET
rk Experience Sheet shall cause the filing of administrative/criminal case/s against the
✘ Dual Citizenship
by naturalization
PUROK 1
Street
SAN AGUSTIN
Barangay
SAMAR
Province
6706
PUROK 1
Street
SAN AGUSTIN
Barangay
SAMAR
Province
6706
N/A
09161980871
OGOTIPROMLIV@GMAIL.COM
DATE OF
BIRTH
(mm/dd/yyyy)
S
C
H
O
L
A
R
S
H
I
P
/
(Continue on separate sheet if necessary)
A
C
A
D
YEAR E
GRADUATED M
I
C
H
04/11/2003 O
N
O
R
3/28/2008 S
R
3/302012
SIGNATURE DATE
CS FORM 212 (Revised 20
LICENSE (if applicable)
Date of
Validity
7/9/2022
GOV'T
SERVICE
(Y/
N)
Y
Y
arate sheet if necessary)
N/A
N/A
COMPUTER LITERATE
(Continue on separate sheet if necessary)
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
CONDUCTED/ SPONSORED BY
(Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
eparate sheet if necessary)
b. within the fourth degree (for Local Government Unit - Career Employees)? YES
If YES, give details:
________________________________
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? RESIGN
________________________________
________________________________
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:
JONATHAN GABRIEL P PAQUIT SAN JORGE, SAMAAR 9177089773 With full and handwritten
name tag and signature over
printed name
NENITA D CODERA SAN AGUSTIN, GANDARA, SAMAR 9398908373
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein.
I agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
administrative/criminal case/s against me.
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.