Professional Documents
Culture Documents
Pallan
Pallan
212
I. PERSONAL INFORMATION
2. SURNAME P allan
NAME EXTENSION (JR., SR)
FIRST NAME C h arles M atth ew
MIDDLE NAME B u en d ia
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 1 0 /2 3 /2 0 0 6 Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH L eg azp i C ity If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female
6 CIVIL STATUS
Single Married 17. RESIDENTIAL ADDRESS P u ro k -s ie te
Widowed Separated House/Block/Lot No. Street/Purok
Other/s: M au raro
Subdivision/Village/Sitio Barangay
7. HEIGHT (m) 164 G u in o b atan Alb ay
City/Municipality Province
8. WEIGHT (kg) 51 ZIP CODE 4503
9. BLOOD TYPE 0+
18. PERMANENT ADDRESS P u ro k -S ie te
House/Block/Lot No. Street/Purok
MIDDLE NAME
OCCUPATION
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
ELEMENTARY 2018
SECONDARY
VOCATIONAL /
TRADE COURSE
COLLEGE
GRADUATE STUDIES
SIGNATURE DATE 0 6 /2 /2 0 1 7
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. NUMBER OF
(Write in full) (mm/dd/yyyy) POSITION / NATURE OF WORK
HOURS
From To
Type of LD
INCLUSIVE DATES OF ATTENDANCE
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS NUMBER OF ( Managerial/ CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
(Write in full) HOURS Supervisory/ (Write in full)
Technical/etc)
From To
10
11
12
13
14
15
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:
35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:
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:
ID/License/Passport No.:
Signature (Sign inside the box)
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.