CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15159109

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 MARIANO
FIRST NAME JOSAL
MIDDLE NAME VISORIO 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS Mangoso, TAPAZ, CAPIZ

4. DATE OF BIRTH (mm/dd/yyyy) 12 / 16 / 1994
5. PLACE OF BIRTH Roxas City
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 5816
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Mangoso, SIGMA, CAPIZ

8. CITIZENDSHIP Filipino
9. HEIGHT (m) 1.49
10. WEIGHT (kg) 48 ZIP CODE 5816
11. BLOOD TYPE O+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) josal_mariano@yahoo.com

13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any) 09301203323
14. PHILHEALTH NO. 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

II. FAMILY BACKGROUND

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

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Mariano

FIRST NAME Jose

MIDDLE NAME Gregorio

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Visorio

FIRST NAME Salvacion

MIDDLE NAME Francisco

III. EDUCATIONAL BACKGROUND

HIGHEST
GRADE/ INCLUSIVE DATES OF
YEAR ATTENDANCE
LEVEL NAME OF SCHOOL DEGREE COURSE LEVEL/ UNITS SCHOLARSHIP/ ACADEMIC
GRADUATED
(Write in full) (Write in full) EARNED HONORS RECEIVED
(if graduated)
(if not
graduated) From To

2001-06- 2007-03-
ELEMENTARY Mangoso, Elementary School 2007
01 01

Vicente Andaya Sr. National 2007-06- 2011-03-

SECONDARY 2011
High School 01 01

VOCATIONAL/ TRADE
COURSE

Capiz State University- Main Bacherlor of 2011-06- 2015-03-

COLLEGE 2015
Campus Secondary Education 01 01

GRADUATE STUDIES

IV. CIVIL SERVICE ELIGIBILITY

MARIANO, JOSAL VISORIO - T15159109 CS FORM 212 (Revised 2005), Page 1 of 3

29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE
LET (LICENSURE EXAMINATION FOR
83.60 03 / 20 / 2016 Iloilo City 1452620 05/19/2016
TEACHER)

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

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

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

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

32. INCLUSIVE DATES OF
ATTENDANCE
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
(Write in full) HOURS (Write in full)
From To

Computer System Servicing NCII 04 / 11 / 2016 06 / 01 / 2016 360 TESDA

Philippine Association for Teachers and Educators VI-Regional Student

02 / 20 / 2015 02 / 21 / 2015 24 PAFTE VI
Congress

Total Quality Classroom Management 02 / 10 / 2015 02 / 10 / 2015 4 Carl E. Balita

Capiz State University-College of

Tree Planting Activity 10 / 12 / 2012 10 / 12 / 2012 4 Education-Society of Future
Science Mentors
Capiz State University-College of
Science Camp 2012 09 / 22 / 2012 09 / 23 / 2012 24 Education-Society of Future
Science Mentors

VIII. OTHER INFORMATION

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

Literary Skills

Computer Skills

MARIANO, JOSAL VISORIO - T15159109 CS FORM 212 (Revised 2005), Page 2 of 3

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

a. Within the third degree (for National Government Employees): YES NO

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 If YES, give details:
appointed? _____________________________________
_____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed?
If YES, give details:
_____________________________________
_____________________________________
_____________________________________

37. a. Have you ever been formally charged? 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 YES NO
regulation by any court or tribunal?
If YES, give details:
_____________________________________
_____________________________________

39. 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, AWOL
or phased out, in the public or private sector? If YES, give details:
_____________________________________
_____________________________________

40. Have you ever been a candidate in a national or local election (except Barangay election)? YES NO
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:

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

If YES, please specify:_______________________
b. Are you differently abled? YES NO
If YES, please specify:_______________________
c. Are you a solo parent? YES NO
If YES, please specify:_______________________

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

NAME ADDRESS TEL. NO.

Ma. Lida A. Solano Panay, Capiz

Wilfredo J. Paulino Sigma, Capiz 09399180725

Susan J. Quistadio Pob. Norte, Sigma, Capiz 09399040118

43. 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.
X
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that
this information shall remain confidential. PHOTO

07322025

COMMUNITY TAX CERTIFICATE NO.

Mangoso, Sigma, Capiz

ISSUED AT SIGNATURE (Sign inside the box)

2016-06-02 09 / 19 / 2016

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

MARIANO, JOSAL VISORIO - T15159109 CS FORM 212 (Revised 2005), Page 3 of 3