Personal Data Sheet, Blank (6'21'10)

CS FORM 212(Revised 2005)
PERSONAL DATA SHEET

*Entries should be handwritten (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 FIRST NAME MIDDLE NAME
GEGUIENTO RONALD REY LOPEZ 6/14/1973 CADIZ CITY

Male Single Married Annulled Female Widowed Separated Others, specify________ 17. TELEPHONE NO. 16. RESIDENTIAL ADDRESS NO.66 MALUNSI SUBD. BRGY.ZONE 3, TALISAY CITY 3. NAME EXTENSION (e.g. Jr.,Sr.)
N/A
4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS
6115 (034)712-7344
ZIP CODE
18. PERMANENT ADDRESS
8. CITIZENSHIP 9. HEIGHT (m) 10. WEIGHT (kg) 11. BLOOD TYPE 12. GSIS ID NO. 13. PAG-IBIG ID NO. 14. PHILHEALTH NO. 15. SSS NO.
FILIPINO 2 2 # Others, specify________ NO. 19. TELEPHONE

20. E-MAIL ADDRESS (if any) 21. CELLPHONE NO.(if any ) 22. AGENCY EMPLOYEE NO. 23. TIN
ZIP CODE
6115
II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS TELEPHONE NO. (Continue on separate sheet if necessary) 26. FATHER'S SURNAME FIRST NAME MIDDLE NAME 27. MOTHER'S MAIDEN NAME SURNAME FIRST NAME MIDDLE NAME 25. NAME OF CHILD(Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
III. EDUCATIONAL BACKGROUND

28. LEVEL NAME OF SCHOOL (Write in full) DEGREE COURSE (Write in full) YEAR GRADUATED (if graduated) HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated) ELEMENTARY INCLUSIVE DATES OF ATTENDANCE From To SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
ESTER A. ARANETA ELEM.S SCHOOL PAGLAUM STATE COLLGE
1986 6th HONOR ##
SECONDARY
VOCATIONAL/ TRADE COURSE
COLLEGE
TECHNOLOGICAL UNIVERSITY OF THE PHILIPPINES LA CONSOLACION COLLEGE-BACOLOD
ONE YEAR
GRADUATE STUDIES
(continue on separate sheet if necessary)
(to be filled up by CSC)
RTH (mm/dd/yyyy)
SCHOLARSHIP/
CADEMIC HONORS RECEIVED
6th HONOR
IV. CIVIL SERVICE ELIGIBILITY

29.
CARRER SERVICE/RA 1080 (BOARD/BAR) UNDER SPECIAL LAWS/CSEE RATING DATE OF EXAMINATION CONFERMENT PLACE OF EXAMINATION/CONFERMENT LICENCE (if applicable) NUMBER
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (include private employment. Start from your current work)
SALARY GRADE INCLUSIVE DATES (MM/DD/YYYY) POSITION TITLE (Write in full) DEPARTMENT/AGENCY/OFFICE/COMPANY (Write in full) MONTHLY SALARY & STEP INCREMENT Format ("00-0")
DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE DEPARTMENT OF PUBLIC WORKS AND HIGHWAYS NEGROS OCCIDENTAL 1ST.DISTRICT ENGINEERING OFFICE
STATUS OF APPOINTMENT
From
6/17/1905
To
(Continue on separate sheet if necessary) CS FORM 212 (revised 2005). Page 2 of 4
CENCE (if applicable) DATE OF RELEASE
GOV'T. SERVICE (Yes/No)
(revised 2005). Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC/NOT-GOVERNMENT/PEOPLE/VOLUNTARY ORGANIZATIONS

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

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

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

34. 33. SPECIAL SKILLS/HOBBIES NON-ACADEMIC DISTINCTIONS/RECOGNITION (Write in full) 35. MAMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
TYPING/ CHESS/ BASKETBALL
N/A
RANK AND FILE EMPLOYEES ASSOCIATION (RAFEA)
(Continue on separate sheet if necessary) CS FORM 212 (revised 2005). Page 3 of 4
N/NATURE OF WORK
TED/SPONSORED BY
Write in full)
AMBERSHIP IN
ON/ORGANIZATION
Write in full)
PLOYEES ASSOCIATION
M 212 (revised 2005). Page 3 of 4
36. Are you related by Consanguinity or affinity to any of the following :
a. 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?
YES
NO
If YES, give details:
b. Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?
YES
NO
37. a. Have you ever been formally charged?
YES
NO
b. Have you ever been guilty of any administrative offense?
YES
NO
38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal?
YES
NO
39. 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?
YES
NO
40. Have you ever been a candidate in a national or local election (except Barangay election)?
YES
NO
41. Pursuant to: (a) Indigenous People Act(RA 8371);(b) Magna Carta for Disabled Persons (RA 7277); and 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 differently abled?
YES
NO
If YES, please specify:
c. Are you a solo parent?
YES
NO
If YES, please specify: 42. REFERENCE (Person not related by consanguinity or affinity to applicant/appointee) NAME ADDRESS TEL. NO.
43. I declare under oath that this Personal Data Sheet has been accomplished by me and is a true, coorect 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.
COMMUNITY TAX CERTIFICATE NO.
ISSUED AT
SIGNATURE (Sign Inside the box)
ISSUED ON (MM/DD/YYYY)
DATE ACCOMPLISHED
RIGHT THUMBMARK
CS FORM 212 (Revised 2005). Page 4 of 4
ID picture taken within the last 6 months 3.5cm. X 4.5cm. (passport size)
Computer generated or xerox copy of picture is not acceptable
PHOTO
RIGHT THUMBMARK
CS FORM 212 (Revised 2005). Page 4 of 4

Personal Data Sheet, Blank (6'21'10)

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Personal Data Sheet, Blank (6'21'10)

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CS FORM 212(Revised 2005)

PERSONAL DATA SHEET

(to be filled up by CSC)

GEGUIENTO RONALD REY LOPEZ 6/14/1973 CADIZ CITY

4. DATE OF BIRTH (mm/dd/yyyy) 5. PLACE OF BIRTH 6. SEX 7. CIVIL STATUS

18. PERMANENT ADDRESS

FILIPINO 2 2 # Others, specify________ NO. 19. TELEPHONE

II. FAMILY BACKGROUND

III. EDUCATIONAL BACKGROUND

ESTER A. ARANETA ELEM.S SCHOOL PAGLAUM STATE COLLGE

1986 6th HONOR ##

VOCATIONAL/ TRADE COURSE

TECHNOLOGICAL UNIVERSITY OF THE PHILIPPINES LA CONSOLACION COLLEGE-BACOLOD

(continue on separate sheet if necessary)

(to be filled up by CSC)

CADEMIC HONORS RECEIVED

IV. CIVIL SERVICE ELIGIBILITY

(Continue on separate sheet if necessary)

(Continue on separate sheet if necessary) CS FORM 212 (revised 2005). Page 2 of 4

CENCE (if applicable) DATE OF RELEASE

GOV'T. SERVICE (Yes/No)

(revised 2005). Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC/NOT-GOVERNMENT/PEOPLE/VOLUNTARY ORGANIZATIONS

N/A N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

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

(Continue on separate sheet if necessary)

VII. OTHER INFORMATION

TYPING/ CHESS/ BASKETBALL

RANK AND FILE EMPLOYEES ASSOCIATION (RAFEA)

(Continue on separate sheet if necessary) CS FORM 212 (revised 2005). Page 3 of 4

M 212 (revised 2005). Page 3 of 4

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

If YES, give details:

If YES, give details:

37. a. Have you ever been formally charged?

If YES, give details:

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

If YES, give details:

If YES, give details:

If YES, give details:

If YES, give details:

a. Are you a member of any indigenous group?

If YES, please specify:

b. Are differently abled?

If YES, please specify:

c. Are you a solo parent?

COMMUNITY TAX CERTIFICATE NO.

SIGNATURE (Sign Inside the box)

CS FORM 212 (Revised 2005). Page 4 of 4

Computer generated or xerox copy of picture is not acceptable

CS FORM 212 (Revised 2005). Page 4 of 4

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