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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 MONSALE
NAME EXTENSION (JR., SR
FIRST NAME MARK ANTHONY
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) monsalemark@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
SURNAME MONSALE
TRADE
COURSE
COLLEGE SOUTHERN MINDANAO COLLEGES
GRADUATE STUDIES
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person
Dual Citizenship
by naturalization
PUROK SANTAN
Street
TAWAGAN SUR
Barangay
ZAMBOANGA DEL SUR
Province
7016
PUROK SANTAN
Street
TAWAGAN SUR
Barangay
ZAMBOANGA DEL SUR
Province
09101765108
monsalemark@gmail.com
SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
2008
2012
2018
OCTOBER 14,2019
CS FORM 212
LICENSE (if applicable)
NUMBER Date of
Validity
0073440 8/5/2022
0060928 8/5/2022
STATUS OF
APPOINTMENT
(Y/
N)
OCTOBER 14,2019
ZAMBOANGA DEL SUR ELECTRIC COOPERATIVE-1 04/17/2017 06/20/2017 320.0 ON-THE-JOB TRAINEE
FISHING
GARDENING
SIGNATURE DATE
RGANIZATION/S
ON-THE-JOB TRAINEE
tive/Managerial positions)
CONDUCTED/ SPONSORED BY
(Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
INSTITUTE OF INTEGRATED ELECTRICAL
ENGINEERS OF THE PHILIPPINES
OCTOBER 14,2019
CS FORM 212 (Revised 2017), Page 3 of 4
34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES
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? ________________________________
________________________________
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:
JEMMELYN M. NABI TAWAGAN SUR PAGADIAN CITY 9104755800 With full and handwritten
name tag and signature over
printed name
JUVET ARTHUR F. TADIAMON TIGUMA, PAGADIAN CITY 9457762331
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.
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.