Professional Documents
Culture Documents
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME PIPKIN
NAME EXTENSION (JR., SR) NONE
FIRST NAME PAULA JANE
MIDDLE NAME MENDOZA
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 10/3/1992 ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH ORMOC CITY, LEYTE please indicate the details. Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS BLOCK 8, LOT 4
Widowed Separate House/Block/Lot No. Street
9. BLOOD TYPE A+
18. PERMANENT ADDRESS BLOCK 8, LOT 4
House/Block/Lot No. Street
10. GSIS ID NO. 2004343332 DECA HOMES CONCEPCION
Subdivision/Village Barangay
ORMOC CITY LEYTE
11. PAG-IBIG ID NO. 121033999804
City/Municipality Province
15. AGENCY EMPLOYEE NO. 4654119 21. E-MAIL ADDRESS (if any) pipkinpaulajane@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A N/A
MIDDLE NAME N/A N/A N/A
OCCUPATION N/A
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME PIPKIN
NAME EXTENSION (JR., SR)
FIRST NAME ROBERT NONE
SURNAME MENDOZA
FIRST NAME ELIZABETH
MIDDLE NAME HEMOTA (Continue on separate sheet if necessary)
VALEDICTO
ELEMENTARY CAGBUHANGIN ELEMENTARY SCHOOL PRIMARY EDUCATION 1998 2004 2004 RIAN
SECONDARY
VOCATIONAL / NEW CITY NATIONAL HIGH SCHOOL HIGH SCHOOL 2004 2008 2008 8TH HONORS
TRADE
BACHELOR OF SECONDARY
COURSE
COLLEGE ST. PETER'S COLLEGE OF ORMOC
EDUCATION - GENERAL SCIENCE
2008 2012 2012 CUM LAUDE
GRADUATE STUDIES VISAYAS STATE UNIVERSITY MASTER OF EDUCATION - BIOLOGY 2015 2017 2017
(Continue on separate sheet if necessary)
SIGNATURE DATE January 24, 2023
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
LICENSURE EXAMINATION FOR TEACHERS 81.8 9/1/2012 TACLOBAN CITY 1179344 10/3/2026
01/19/2023 PRESENT SECONDARY SCHOOLTEACHER III VALENCIA NATIONAL HIGH SCHOOL - DEPED 31, 633.00 13-2 PERMANENT Y
02/16/2022 12/14/2022 SECONDARY SCHOOLTEACHER III VALENCIA NATIONAL HIGH SCHOOL - DEPED 30, 111.00 13-2 PERMANENT Y
02/26/2021 01/25/2022 SECONDARY SCHOOLTEACHER III VALENCIA NATIONAL HIGH SCHOOL - DEPED 28, 276.00 13-1 PERMANENT Y
02/26/2020 01/26/2021 SECONDARY SCHOOLTEACHER III VALENCIA NATIONAL HIGH SCHOOL - DEPED 26, 754.00 13-1 PERMANENT Y
04/08/2019 01/17/2020 SECONDARY SCHOOLTEACHER III VALENCIA NATIONAL HIGH SCHOOL - DEPED 25, 232.00 13-1 PERMANENT Y
02/08/2018 03/08/2019 SECONDARY SCHOOLTEACHER III VALENCIA NATIONAL HIGH SCHOOL - DEPED 24, 224.00 13-1 PERMANENT Y
01/01/2018 02/07/2018 SECONDARY SCHOOL TEACHER I VALENCIA NATIONAL HIGH SCHOOL - DEPED 19, 853.00 11-2 PERMANENT Y
01/01/2017 12/31/2017 SECONDARY SCHOOL TEACHER I VALENCIA NATIONAL HIGH SCHOOL - DEPED 19, 853.00 11-2 PERMANENT Y
01/01/2016 12/31/2016 SECONDARY SCHOOL TEACHER I VALENCIA NATIONAL HIGH SCHOOL - DEPED 19, 077.00 11-2 PERMANENT Y
01/01/2015 12/31/2015 SECONDARY SCHOOL TEACHER I VALENCIA NATIONAL HIGH SCHOOL - DEPED 18, 549.00 11-1 PERMANENT Y
01/01/2014 12/31/2014 SECONDARY SCHOOL TEACHER I VALENCIA NATIONAL HIGH SCHOOL - DEPED 18, 549.00 11-1 PERMANENT Y
05/15/2013 12/31/2013 SECONDARY SCHOOL TEACHER I VALENCIA NATIONAL HIGH SCHOOL - DEPED 18, 549.00 11-1 PERMANENT Y
05/12/2012 03/30/2013 PRIVATE SCHOOL TEACHER LIDE Learning Center Inc. (LLCI) 15, 500.00 N/A CONTRACTUAL N
NATIONAL VIRTUAL IN-SERVICE TRAINING 2.0 08/30/2021 09/03/2021 40 TECHNICAL DEPED ICTS-EdTech / OUCI /OUFO
DIVISION-WIDE QUALITY ASSURANCE OF SLM FOR STE ADD-ON
SUBJECTS UNDER THE SCIENCE, TECHNOLOGY AND 07/30/2021 08/04/2021 32 TECHNICAL DEPED - ORMOC CITY DIVISION
ENGINEERING
Development and Quality AssurancePROGRAM
(QA) of Self-Learning Modules
(SLMs) for the Add-On Subjects under the Science, Technology, 07/19/2021 07/23/2021 24 TECHNICAL DEPED - REGION VIII
Engineering Program
DISTRICT SEMINAR-WORKSHOP ON ACTION RESEARCH FOR
SCHOOL HEADS AND TEACHERS
06/01/2021 06/03/2021 24 TECHNICAL DISTRICT VI ORMOC CITY DIVISION
3-DAY VIRTUAL DIVISION RESEARCH TRAINING 12/16/2020 12/18/2020 24 TECHNICAL DEPED - ORMOC CITY DIVISION
IN-SERVICE TRAINING (INSET) 12/15/2020 12/17/2020 24 DEPED - VALENCIA NAT'L HIGH SCHOOL
TECHNICAL
AFTA'S BALIKTURO ONLINE 2020 07/21/2020 07/25/2020 22 TECHNICAL AFTA, Inc. & DEPED
3-DAY DIVISION-BASED WEBINAR ON EBOOK DESIGNING AND
OPEN EDUCATION RESOURCES DEVELOPMENT
05/19/2020 05/21/2020 24 TECHNICAL DEPED-ORMOC CITY DIVISION
EMPOWERING HIGH SCHOOL TEACHERS THROUGH STRATEGIES 07/28/2018 07/29/2018 ABS-CBN LINGKOD KAPAMILYA-
16 TECHNICAL
IN CLASSROOM MANAGEMENT DEPED
TRAINING ON COMMUNICATING VOLCANO, EARTHQUAKE AND 04/24 2018 04/26/2018
24 TECHNICAL PHIVOLCS/DEPED - ORMOC CITY DIV.
TSUNAMI HAZARDS
ENHANCEMENT TRAINING FOR SCIENCE HIGH SCHOOL 04/16/2018 04/21/2018 48 TECHNICAL VSU/DEPED - ORMOC CITY DIVISION
TEACHERS (PHYSICS CONTENT)
(Continue on separate sheet if necessary)
SIGNATURE DATE 01/24/2024
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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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 NO
YES ✘
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? NO
YES ✘
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:
HELEN B. FUENTES MATICA-A, ORMOC CITY 0919-095-2174 With full and handwritten
name tag and signature over
printed name
LENGIE DALUPAN-GABI COGON, ORMOC CITY 0923-148-8660
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.
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.