CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15325112

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 JUNIO
FIRST NAME JENNIFER
MIDDLE NAME RAMIREZ 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS Brgy. Wawa, BAYAMBANG, PANGASINAN

4. DATE OF BIRTH (mm/dd/yyyy) 04 / 04 / 1987
5. PLACE OF BIRTH Pangasinan
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 2423
Married Separated
17. TELEPHONE NO. N/A
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Brgy. Wawa, BAYAMBANG, PANGASINAN

8. CITIZENDSHIP Filipino
9. HEIGHT (m) 5'2
10. WEIGHT (kg) 165LBS ZIP CODE 2423
11. BLOOD TYPE O+ 19. TELEPHONE NO. N/A
12. GSIS ID NO. N/A 20. EMAIL ADDRESS (if any) ishrivadrniera@gmail.com
13. PAGIBIG ID NO. N/A 21. CELLPHONE NO. (if any) 0912-1829-246
14. PHILHEALTH NO. 05-025651653-2 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. 3406251489 23. TIN N/A

II. FAMILY BACKGROUND

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

FIRST NAME Fernando Jennina Fiona R. Junio 05 / 10 / 2018

MIDDLE NAME Cuison

OCCUPATION Farming

EMPLOYER/BUS. NAME

BUSINESS ADDRESS Bayambang, Pang.

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Ramirez

FIRST NAME Isidro

MIDDLE NAME Mercado

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Gabriel

FIRST NAME Genita

MIDDLE NAME Macaraeg

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

ELEMENTARY Bakitiw, Elementary School 1999 1992 1999

Domingo P. Boquiren
SECONDARY 2003 1999 2003 5th Honors
Memorial High School

VOCATIONAL/ TRADE
COURSE

Pangasinan State University, Bachelor of 2007-03-

COLLEGE 2007 2003
Bayambang Campus Secondary Education 29

GRADUATE STUDIES

IV. CIVIL SERVICE ELIGIBILITY

JUNIO, JENNIFER RAMIREZ - T15325112 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
75.2 03 / 26 / 2017 Rosales, Pangasinan 1550295 06/22/2017

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")

Immaculate Heart of Mary School

05/25/2011 03/31/2016 Teacher 9,000 0-0 Probationary No
Malabon

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

NA NA NA NA NA

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

Kadsa as Communion of Communities, Embracing the Joy of God's Mercy 10 / 21 / 2016 10 / 21 / 2016 10 KADSA

VIII. OTHER INFORMATION

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

Baking Na Na

JUNIO, JENNIFER RAMIREZ - T15325112 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:
Finished contract

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.

Dr. Severino M. Jocson Jr. Malabon 446-4320

Mrs. Antonina Aquino Malabon 09236107554

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

03312483

COMMUNITY TAX CERTIFICATE NO.

Bayambang Pangasinan

ISSUED AT SIGNATURE (Sign inside the box)

2019-01-21 01 / 21 / 2019

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

JUNIO, JENNIFER RAMIREZ - T15325112 CS FORM 212 (Revised 2005), Page 3 of 3