Professional Documents
Culture Documents
Personal Data Sheet New
Personal Data Sheet New
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME
NAME EXTENSION (JR., SR)
FIRST NAME
MIDDLE NAME
3. DATE OF BIRTH
(mm/dd/yyyy) APRIL 9, 1984 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH LALA, LANAO DEL NORTE If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) norielvillaver@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yy
NAME EXTENSION (JR., SR) N/A
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
SURNAME CANOY
SECONDARY
VOCATIONAL / CENTRAL MINDANAO TECHNICAL INSTITUTE SECONDARY 6/6/1998 3/30/2002 2002
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page
AL DATA SHEET
Experience Sheet shall cause the filing of administrative/criminal case/s against the person
by naturalization
Pls. indicate country:
PUROK POLIPOG
Street
PINOYAK
Barangay
LANAO DEL NORTE
Province
PUROK POLIPOG
Street
PINOYAK
Barangay
LANAO DEL NORTE
Province
N/A
09656856561
norielvillaver@gmail.com
SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
TOP 2
TOP 10
N/A
N/A
ue on separate sheet if necessary)
NONE
7/10/2018 7/13/2021 FARM MANAGER Lucky 9 Grains and Conditioner 12000.00 N/A CONTRACTUAL N
5/8/2016 12/9/2017 STORE MANAGER Lucky 9 Grains and Conditioner 12000.00 N/A CONTRACTUAL N
06/22/2014 8/7/2016 CASHIER and INVENTORY STAFF Anchang Poultry Supplier 8000.00 N/A CONTRACTUAL N
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To
NONE
SIGNATURE DATE
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 ✘
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:
KAREM M. BARTOLOME TUBOD, LANAO DEL NORTE 9655240090 With full and handwritten
name tag and signature over
printed name
MADELYN M. CABATAN LALA, LANAO DEL NORTE 9350636629
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.
ID/License/Passport No.:
Signature (Sign inside the box)
SEPTEMBER 12, 2022
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.