CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "P " and use separate form if necessary.

1. CS ID No.

(to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME FIRST NAME MIDDLE NAME

VELASQUEZ JONNA BACOD

7/23/1970 16. RESIDENTIAL ADDRESS 178 M. De Castro St. Bagong Barrio Caloocan City Sta. Lutgarda, Macabebe, Pampanga 3. NAME EXTENSION (e.g. Jr., Sr.)

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

Male Single Married Annuled

Female Separated Widowed

ZIP CODE 1400

17. TELEPHONE NO. Others specify: 18. PERMANENT ADDRESS ________________________ 178 M. De Castro St. Bagong Barrio Caloocan City

8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11. BLOOD TYPE 12. GSIS ID NO. 13. PAG-IBIG ID NO. 14. PHILHEALTH NO. 15. SSS NO.

Filipino 1.62m 64kg O 2004007288 ZIP CODE 19. TELEPHONE NO.

1400

20. E-MAIL ADDRESS (if any)oenazki_23@yahoo. Com J 21. CELLPHONE NO. (if any)09395325474

03 050057804 8 33 0285526 4

22. AGENCY EMPLOYEE NO.4543890 23. TIN 222 263 438

II. FAMILY BACKGROUND

24.SPOUSE'S SURNAME VELASQUEZ 25. NAME OF CHILD (Write full name and list all) OF BIRTH (mm/dd/yyyy) DATE Chrizelle Jean B. Velasquez Chrizalette Joie B. Velasquez 07/05/95 07/09/06 FIRST NAME G L E I N F O R D MIDDLE NAME C A G A O A N OCCUPATION Offset Operator

EMPLOYER/BUS. NAME Industrial Offset Inc. BUSINESS ADDRESS TELEPHONE NO. 58 A. Bonifacio Ave., Barangka, Marikina City 941 20 94

(Continue on separate form if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME B A C O D Sr. JOSE DURAN

27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME SUGA JULIETA MERCADO YEAR GRADUATE D DEGREE COURSE (Write in full) (Continue on separate form if necessary) HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated)

III. EDUCATIONAL BACKGROUND

28. LEVEL NAME OF SCHOOL (Write in full) Bagong Barrio Elementary School

INCLUSIVE DATES OF ATTENDANCE From To

SCHOLARSHIP/ ACADEMIC HONORS RECEIVED

ELEMENTARY

(if 1983 graduated )

1987

SECONDARY / VOCATIONAL

Araneta University Extension

COLLEGE TRADE COURSE

Gregorio Araneta University Foundation

Bachelor of Science in Secondary Education. Maj. In Filipino M. A. in Education maj. In Administration and Supervision

1999

Dean Lister

GRADUATE STUDIES

Dr. Carlos S. Lanting College

15

2005

2006

(Continue on separate form if necessary) Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE Lisensure Examination for Teacher RATING DATE OF EXAMINATIO N/ CONFERMENT Aug. 27, 2000 LICENSE (if applicable) PLACE OF EXAMINATION / CONFERMENT NUMBER DATE OF RELEASE

75.00%

Manuel L. Quezon University

0752965 Oct. 4, 2000

(Continue on separate form if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES (mm/dd/yyyy) From 6/18/2010 6/8/2009 To present POSITION TITLE (Write in full) Filipino Teacher DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY (Write in SALARY full) Macario B. Asistio Sr. High School Bagong Barrio National High School Dr. Carlos S. Lanting College 10,405.0 0 12,600.0 0
SALARY GRADE & STATUS OF STEP APPOINTMEN INCREMENT T (Format "000")

GOV'T SERVICE

Permanen t LSB Permanen t

(Yes / No) YES

3/31/2010 Finlipino Teacher Elem. & High Filipino Teacher

YES NO

June, 2000 5/27/2009

(Continue on separate form if necessary) CS FORM 212 (Revised 2005), Page 2 of 4

Oct. 4, 2000

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY O

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

(Continue on separate form if necessary)

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

32. TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)
INCLUSIVE DATES OF ATTENDANCE (mm/dd/yyyy)

NUMBER CONDUCTED/ SPONSORED BY OF HOURS (Write in full)

From Summer 2011 School Based in-Service Training For Teachers Istratehiya ng Pagtuturo ng Wika at Panitikan The Innovative Mind-Body-Voice ISO 9001: 2000 Familiarization Seminar Personal and Professional Effectiveness Values Formation and Work Ethics Showcasing Integration in the 2000 Basic Curriculum via New Teaching Strategy Teaching for Relevance 5/30/2011 9/27/2008

To 6/3/2011 40 hrs Macario B. Asistio Sr. High School Filipino Centrex APSA Dr. Dr. Carlos S. Lanting College

5/5/2007 Carlos S. Lanting College 6/10/2005 7/23/2005 7/23/2005 1/24/2004 11/15/2003 S. Lanting College

Dr. Carlos

Dr. Carlos S. Lanting College House Phoenix Publishing

Rex Bookstore, Inc

(Continue on separate form if necessary)

VIII. OTHER INFORMATION

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

MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)

Computer Literate Knowledgeable in Clerical Job Art Works Playing Volleyball

(Continue on separate form if necessary) CS FORM 212 (Revised 2005), Page 3 of 4

36. Are

you related by consanguinity or affinity to any of the following :

YES NO

a. Within

the third degree (for National Government Employees): appointing authority, recommending authority, chief of office/bureau/department or person who has immediate supervision over you in the Office, Bureau or Department where you will be appointed? the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? Have you ever been formally charged?

b. Within

37 a.

If YES, give details: _____________________________________________ ____________________________________ __________________ _ ____________________________________ _ ____________________________________ YES NO _ If YES, give details: _____________________________________________ ____________________________________ __________________ _ ____________________________________ _ 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 regulation by any court or tribunal?

YES

NO

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 phased out, in the public or private sector? you ever been a candidate in a national or local election (except Barangay election)?

YES

NO

If YES, give details: _____________________________________________ ________________________________ __________________ __ ________________

YES NO

40. Have

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: Are you a member of any indigenous group?
YES NO

a.

If YES, please specify:

______________________________________ b.

Are you differently abled?

YES

If YES, please specify:

______________________________________ c.

NO

Are you a solo parent?

YES

NO

If YES, please specify:

______________________________________ 42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee) NAME Ma. Victoria David Ptr. Lee Oliver Virginia A. Diokno 43. I ADDRESS TEL. NO.
ID picture taken within the last 6 months 3.5 cm. X 4.5 cm (passport size) Computer generated or xerox copy of picture is not acceptable

M. De Castro St. Bagong Barrio, Cal City 14 637 10 302 PPI Bldg. EDSA Bagong Barrio Cal City 9192357455 Dr. Carlos S. Lanting College 9094537655

declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and 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.
16201843 COMMUNITY TAX CERTIFICATE NO. Caloocan City ISSUED AT 3/4/2011 ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED SIGNATURE (Sign inside the box)

PHOTO

RIGHT THUMBMARK

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