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 Q |U | I| M| B | O | | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME R |E | X | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME C |A | R |E | L |O | R | I |A | | | | | | | | | | NAME EXTENSION (e.g. Jr., Sr.)

3.
16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy) 12/02/1997
5. PLACE OF BIRTH CALUBIAN, LEYTE BRGY. LUCSOON NAVAL, BILIRAN
6. SEX Male Fem ale
7. CIVIL STATUS Single Widowed ZIP CODE 6543
Married Separated
17. TELEPHONE NO. N/A
Annulled Others, specify ___________ 18. PERMANENT ADDRESS

8. CITIZENSHIP FILIPINO BRGY. LUCSOON NAVAL, BILIRAN

9. HEIGHT (m) 1.82 m
10. WEIGHT (kg) 62 kg ZIP CODE 6543
11. BLOOD TYPE N/A 19. TELEPHONE NO. N/A
12. GSIS ID NO. N/A 20. E-MAIL ADDRESS (if any) rex.quimbo.50@gmail.com
13. PAG-IBIG ID NO. N/A 21. CELLPHONE NO. (if any) 09491590295 / 09561221812
14. PHILHEALTH NO. N/A 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. N/A 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 12.../...15..../..2004

MIDDLE NAME N/A 12.../...15..../..2004
OCCUPATION N/A 12.../...15..../..2004
EMPLOYER/BUS. NAME N/A 12.../...15..../..2004
BUSINESS ADDRESS N/A 12.../...15..../..2004
TELEPHONE NO. N/A 12.../...15..../..2004
(Continue on separate sheet if necessary) 12.../...15..../..2004
26. FATHER'S SURNAME QUIMBO 12.../...15..../..2004
FIRST NAME ERIC 12.../...15..../..2004
MIDDLE NAME JAMOT 12.../...15..../..2004
27. MOTHER'S MAIDEN NAME LOLITA BADILLA CARELORIA 12.../...15..../..2004
SURNAME QUIMBO 12.../...15..../..2004
FIRST NAME LOLITA 12.../...15..../..2004
MIDDLE NAME CARELORIA (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
CALUBIAN SOUTH CENTRAL graduated)
ELEMENTARY PRIMARY 2009 6/-/2003 -/-/2009 N/A
SCHOOL
CALUBIAN NATIONAL HIGH
SECONDARY SECONDARY 2013 6/-/2009 -/-/2013 N/A
VOCATIONAL / SCHOOL
N/A N/A N/A N/A N/A N/A
TRADE
COLLEGE
COURSE
BACHELOR OF
SECONDARY
LEYTE NORMAL UNIVERSITY EDUCATION -
2017 -/-/2013 -/-/2017 N/A
MAPEH
GRADUATE STUDIES
N/A N/A N/A N/A N/A 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
BOARD LICENSURE EXAMINATION
81.00% 9/30/2018 TACLOBAN CITY 1733693
FOR PROFESSIONAL TEACHERS

(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)
N/A N/A N/A N/A N/A N/A N/A N/A

(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

N/A 02../.13./.1997 02../.13./.1997

N/A 02../.13./.1997 02../.13./.1997

N/A 02../.13./.1997 02../.13./.1997

N/A 02../.13./.1997 02../.13./.1997

N/A 02../.13./.1997 02../.13./.1997

(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
PHILIPPINE SPORTS
REBISCO VOLLEYBALL ACADEMY COACHES COURSE LEVEL
04/12/2021 04/16/2021 32 hours COMMISSION/REBISCO
I
VOLLEYBALL ACADEMY
PHILIPPINE SPORTS
REBISCO VOLLEYBALL LEAGUE ACCREDITED VOLLEYBALL
04/12/2021 04/16/2021 32 hours COMMISSION/REBISCO
COACH
VOLLEYBALL ACADEMY
JE MONDEJAR COMPUTER
10 DAYS BASIC COMPUTER LITERACY TRAINING 02/22/2019 03/07/2019 80 hours
COLLEGE

(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)
AWARD OF RECOGNITION-NATIONAL SCUAA ATHLETE CALUBIAN VOLLEYBALL
VOLLEYBALL PLAYER AND COACH 2017 (VOLLEYBALL) ASSOCIATION
AWARD OF MERIT - REGIONAL SCUAA GAMES MEDALIST
COMPUTER LITERATE 2016 (VOLLEYBALL)

SINGING

DANCING

(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 YES NO

degree (for National Government Employees):
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 fourthdegree (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,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL or YES NO
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)?

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.

MR. JERAULD LIRIOS TACLOBAN CITY N/A

ID picture taken within
the last 6 months
MR. ROMYR GABON TACLOBAN CITY N/A 3.5 cm. X 4.5 cm
(passport size)

Computer generated
43. I declare under oaththat this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

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

COMMUNITY TAX CERTIFICATE NO.

ISSUED AT SIGNATURE (Sign inside the box)

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

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