Personal Data Sheet 2015 Tesda

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 D | E | L | A | | R | O | S | A | | | | | | | | | | | | | | | | | | | | | | |

FIRST NAME D | E | M | E | T | R | I | O | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE NAME B | A | R | R | O | Z | O | | | | | | | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.) JR/

4. DATE OF BIRTH (mm/dd/yyyy) 06/03/1978 16. RESIDENTIAL ADDRESS

107 TAMBAC DISTRICT, DAGUPAN CITY, PANGASINAN5. PLACE OF BIRTH DAGUPAN CITY

6. SEX

7. CIVIL STATUS ZIP CODE 2400

17. TELEPHONE NO. 0907759652318. PERMANENT ADDRESS

107 TAMBAC DISTRICT, DAGUPAN CITY, PANGASINAN8. CITIZENSHIP FILIPINO

9. HEIGHT (m) 5'8"

10. WEIGHT (kg) 65 KG ZIP CODE 2400

11. BLOOD TYPE 0 19. TELEPHONE NO. 09077596523

GSIS ID NO. 20. E-MAIL ADDRESS (if any)

13. PAG-IBIG ID NO. 121047692027 21. CELLPHONE NO. (if any) 09077596523

14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 216843815 23. TIN 214583057000

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME DELA ROSA 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME VIRGIE DEVIE U. DELA ROSA 04/16/2008

MIDDLE NAME UBANDO DEMVER U. DELA ROSA 05/21/2011

OCCUPATION N/A / /

EMPLOYER/BUS. NAME N/A / /

BUSINESS ADDRESS N/A / /

TELEPHONE NO. / /

(Continue on separate sheet if necessary) / /

26. FATHER'S SURNAME DELA ROSA SR. 06/21/1954

FIRST NAME DEMETRIO / /

MIDDLE NAME ANDRES / /

27. MOTHER'S MAIDEN NAME / /

SURNAME DELA ROSA 06/24/1961

FIRST NAME ESPERANZA / /

MIDDLE NAME BARROZO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

28.LEVEL

From To

ELEMENTARY TAMBAC ELEMENTARY SCHOOL 1991 1991

SECONDARY ST. JOHN CATHEDRAL HIGH SCOOL 1995 1991 1995

COLLEGEUNIVERSITY OF PANGASINAN 200 1995 2000

GRADUATE STUDIES M.A. IN MATHEMATICS 2000 2007 2009

(Continue on separate sheet if necessary)

Page 1 of 4

12. [email protected]

NAME OF SCHOOL (Write in

full)DEGREE COURSE (Write in full)

YEAR GRADUATED (if graduated)

HIGHEST GRADE/ LEVEL/

UNITS EARNED (if not graduated)

INCLUSIVE DATES OF ATTENDANCE SCHOLARSHIP/ ACADEMIC HONORS

RECEIVED

VOCATIONAL / TRADE COURSE

BACHELOR OF SCIENCE IN COMPUTER ENGINEERING

THE MOST RECEPIENT IN DESIGN PROJECT IN BSCPE

DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY

Annulled Others, specify ___________

Single

Married

Widowed

Separated

Male Female

mailto:[email protected]

IV. CIVIL SERVICE ELIGIBILITY

29.RATING PLACE OF EXAMINATION / CONFERMENT

LICENSE (if applicable)

NUMBERDATE OF RELEASE

PROFESSIONAL CAREER SERVICE 84.50% 07/24/2002 CSC CAR REGION 0401014WE 07/24/2002

10/24/2008 TESDA LINGAYEN, PANGASINAN 09010402003970 02/15/2009


V. WORK EXPERIENCE (Include private employment. Start from your current work)

30. INCLUSIVE DATES (mm/dd/yyyy)MONTHLY SALARY

From To

07/16/2000 01/ 16/2003 MIS Staff JAPAN CIRCUIT TECHNOLOGY CORPORATION/Procurement Department 10000 REGULAR NO

03 /12/2003 04 / 28 /2009 IT Instructor University of Luzon 12000 REGULAR NO

09 / 11/2009 03 /28 /2012 Don Mariano Marcos Memorial State University 19000 REGULAR yes

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CS FORM 212 (Revised 2005), Page 2 of 4

CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE

DATE OF EXAMINATION / CONFERMENT

NATIONAL CERTIFICATE(NC-2) COMPUTER HARDWARE SERVICING

POSITION TITLE

(Write in full)DEPARTMENT / AGENCY / OFFICE / COMPANY

(Write in full)SALARY GRADE & STEP INCREMENT

(Format "00-0")STATUS OF

APPOINTMENT

GOV'T SERVICE

(Yes / No)

Computer Instructor/Researcher

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

31.POSITION / NATURE OF WORK

From To

ASSOCIATION OF COMPUTER ENGINEERING STUDENT COUNCIL 06 / 12 /1995 06/ 1 /1997 320 HOURS MEMBER OF STUDENT COUNCIL

/ / / /

/ / / /

/ / / /

/ / / /


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

32.TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)

From To

DATA COMMUNICATIONS AND NETWORKING 08/21/1999 08/22 /1999 16 HOURS NATIONALCOMPUTER CENTER

WEBPAGE DESIGN AND NETWORKING 08/06/1999 08/07/1999 16 HOURS CFE COMPUTERS

TMTP 1 02/02/2009 02 /06 /2009 34 HOURS TESDA LINGAYEN PANGASINAN

CAMC 05/11/2009 05/15 /2009 34 HOURS TESDA LINGAYEN PANGASINAN

ISO 14001 and ISO 9001(Quality Management and Environment Awareness) 06/21/2000 06 / 22 /2000 16 HOURS Japan Circuit Technology Corporation

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VIII. OTHER INFORMATION

33. SPECIAL SKILLS / HOBBIES: 34. 35.



NAME & ADDRESS OF ORGANIZATION (Write in full)

INCLUSIVE DATES

(mm/dd/yyyy) NUMBER OF HOURS

INCLUSIVE DATES OF ATTENDANCE

(mm/dd/yyyy) NUMBER OF HOURS

CONDUCTED/ SPONSORED BY (Write in full)

NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)

INTERNET, CHESS, BASKETBALL, BADMINTON ETC.

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

a.

b.

37 a. Have you ever been formally charged?

b. Have you ever been guilty of any administrative offense?

38.

39.

40. Have you ever been a candidate in a national or local election (except Barangay election)?

41.

a. Are you a member of any indigenous group?If YES, please specify: ____________________

b. Are you differently abled?If YES, please specify: ____________________

c. Are you a solo parent?If YES, please specify: ____________________

42.

NAME ADDRESS TEL. NO.

ENGR. CHRISTOPHER FERNANDEZ MANGALDAN, PANGASINAN

RENE MOYANO MANGALDAN, PANGASINAN

43.

PHOTO

14284259

COMMUNITY TAX CERTIFICATE NO.

DAGUPAN CITYISSUED AT

03/12/2014 11/26/2014ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK


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?

If YES, give details: _____________________________________ _____________________________________ _____________________________________

Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? If YES, give details:

_____________________________________ _____________________________________ _____________________________________

If YES, give details: _______________________________ ________________________________

If YES, give details: ________________________________ ________________________________

Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? If YES, give details:

________________________________ ________________________________

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?



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:

REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

I 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.

SIGNATURE (Sign inside the box)

ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)

Computer generated or xerox copy of picture

is not acceptable

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

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Personal Data Sheet 2015 Tesda