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 filledup by CSC)

I. PERSONAL INFORMATION
2.

SURNAME
FIRST NAME

G A B E

M A B

A N

3. NAME EXTENSION (e.g. Jr., Sr.)

MIDDLE NAME
4.

DATE OF BIRTH (mm/dd/yyyy)

5.

PLACE OF BIRTH

6.

SEX

7.

CIVIL STATUS

I
11/21/1992

17.

POBLACION 1-A, MOTIONG, WESTERN SAMAR

RESIDENTIAL ADDRESS

CATBALOGAN CITY, SAMAR

Male

Single

Female
18.

Married

Separated

Annulled

Others, specify _______ 19.

8.

CITIZENSHIP

FILIPINO

9.

RELIGION

ROMAN CATHOLIC

6702

ZIP CODE

Widowed

TELEPHONE NO.

N/A

PERMANENT ADDRESS

POBLACION 1-A, MOTIONG, WESTERN SAMAR

10. HEIGHT (m)

1.7 m

11. WEIGHT (kg)

73 kgs.

12. BLOOD TYPE

20.

TELEPHONE NO.

N/A

13. GSIS ID NO.

N/A

21.

E-MAIL ADDRESS (if any)

gemvince@gmail.com

14. PAG-IBIG ID NO.

121098655423

22.

CELLPHONE NO. (if any)

+639093850362 / +639362184285

15. PHILHEALTH NO.

130251538213

23.

AGENCY EMPLOYEE NO.

N/A

16. SSS NO.

06-3369681-0

24.

TIN

N/A

ZIP CODE

6702

II. FAMILY BACKGROUND

N/A

25. SPOUSES SURNAME

FIRST NAME

N/A

MIDDLE NAME

N/A

EMPLOYER/BUS. NAME

N/A
N/A

BUSINESS ADDRESS

N/A

TELEPHONE NO.

N/A

OCCUPATION

26. NAME OF CHILD (Write in full name and list all)

DATE OF BIRTH (mm/dd/yyyy)

N/A

N/A

(Continue on separate sheet if necessary)

27. FATHERS SURNAME

GABEJAN

FIRST NAME

AMADO

MIDDLE NAME

LAGBO

OCT. 12, 1956

28. MOTHERS MAIIDEN NAME

SURNAME

MABINI

MAY 8, 1950

FIRST NAME

ROSITA

MIDDLE NAME

TENEDERO

(Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

29.
NAME OF SCHOOL
(Write in full)

DEGREE / COURSE
(Write in full)

YEAR
GRADUATED
(If graduated)

HIGHEST GRADE /
LEVEL / UNITS
EARNED
(if not graduated)

ELEMENTARY

MOTIONG CENTRAL ELEM. SCHOOL

ELEMENTARY GRADUATE

2005

SECONDARY

WRIGHT NATIONAL HIGH SCHOOL

SECONDARY GRADUATE

LEVEL

VOCATIONAL /
TRADE COURSE
COLLEGE

INNOVATE ICT SYSTEMS INC.

SAMAR STATE UNIVERSITY

COMPUTER HARDWARE
SERVICING NCII
BACHELOR OF SCIENCE
IN INFORMATION
TECHNOLOGY

INCLUSIVE DATES OF
ATTENDANCE
FROM

TO

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

GRADUATED

JUNE 1999

APRIL 2005

3RD HONOR

2009

GRADUATED

JUNE 2005

APRIL 2009

N/A

2013

GRADUATED

APRIL 2013

JUNE 2013

N/A

2013

GRADUATED

JUNE 2009

APRIL 2013

N/A

23 UNITS

JUNE 2015

PRESENT

N/A

GRADUATE STUDIES

SAMAR STATE UNIVERSITY

DIPLOMA IN TEACHING

Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

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

RATING

Date of Examination /
Conferment

LICENSE (if applicable)

Place of Examination /
Conferment

Number

Date of Release

(Continue on separate sheet, if necessary)

V. WORK EXPERIENCE (Include private employment. Start from most recent work experience.)
31.
INCLUSIVE DATES
(mm/dd/yyyy)
From

10/21/2013

POSITION TITLE
(Write in full)

DEPARTMENT / AGENCY / OFFICE

(Write in full)

MONTHLY
SALARY

ENCODER/WAREHOUSE
CHECKER

FAST DISTRIBUTION
CORPORATION

8,000.00

To

02/12/2015

SALARY
GRADE &
STEP
INCREMENT

STATUS OF
APPOINTMENT

GOVT.
SERVICE
(Yes / No)

REGULAR

NO

(Continue on separate sheet if necessary)

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

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

32.

INCLUSIVE DATES
(mm/dd/yyyy)

NAME & ADDRESS OF ORGANIZATION

(Write in full)
N/A

FROM

TO

N/A

N/A

NUMBER OF
HOURS

POSITION / NATURE OF WORK

N/A

N/A

NUMBER OF
HOURS

CONDUCTED / SPONSORED BY
(Write in full)

(Continue on separate sheet, if necessary)

VII. TRAINING PROGRAMS / STUDY / SCHOLARSHIP GRANTS (Start from the most recent training.)
33.

INCLUSIVE DATES OF ATTENDANCE

(mm/dd/yyyy)

TITLE OF SEMINAR / CONFERENCE / WORKSHOP

(Write in full)

FROM

TO

Food Processing NCII

06/01/2015

10/23/2015

Computer Hardware Servicing NCII

05/20/2013

06/02/2013

240

Innovate ICT Systems Inc.,

Catbalogan City

GapLabs WebCamp

02/23/2013

02/24/2014

16

GoAbroad Philippines

2013 College of Arts and Sciences Enrichment Program

02/15-16,2223/2013

03/01/2013

40

SSU CAS Department

Leyte Samar IT Summit (LESITS)

09/07/2012

09/07/2012

HyperWorx Tacloban City

04/01/2012

05/30/2012

120

Innovate ICT Systems, Inc.,

Tacloban City

On-the-Job Training

Mrs. Elena M. Bagatsolon

(Continue on separate sheet, if necessary)

VIII. OTHER INFORMATION

34.

SPECIAL SKILLS / HOBBIES

35. NON-ACADEMIC DISTINCTIONS / RECOGNITION

(Write in full)

36.

MEMBERSHIP IN ASSOCIATION /
ORGANIZATION
(Write in full)

Microsoft Office Proficient (e.g. Word, Excel, PPT)

Computer Reformatting
Computer Software Applications Enthusiast
Computer Hardware Servicing NCII

(Continue on separate sheet, if necessary)

CS FORM 212 (Revised 2005), Page 3 of 4

37.

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 or office / bureau / department or person who has
immediate supervision over you in the Office, Bureau or Department where you will be appointed?

b.

Within the fourth degree (for LOCAL GOVERNMENT Employees):

appointing authority, recommending authority where you will be appointed?

38.

a. Have you ever been formally charged?

NO
YES
If YES, give details:
____
.
____________________________________________
NO
YES
If YES, give details:
___
.
____________________________________________

NO
YES
If YES, give details:
__
.
____________________________________________
NO
YES
If YES, give details:
__
.
____________________________________________

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

39.

Have you ever been convicted of any crime or violation of any law, decree, ordinance or
regulation by any court or tribunal?

40.

Have you ever been separated from the service in any office 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?

NO
YES
If YES, give details:
___
.
____________________________________________
NO
YES
If YES, give details:

.____________
____________________________________________
41.

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

42.

Pursuant to: (a) indigenous Peoples 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:

NO
YES
If YES, give details:
__
.
____________________________________________

NO
YES
If YES, give details:

a. Are you a member of any indigenous group?

b. Are you differently abled?

YES
NO
If YES, give details:

c. Are you a solo parent?

YES
NO
If YES, give details:

43. REFERENCES (Persons not related by consanguinity or affinity to applicant / appointee)

NAME

ADDRESS

TELEPHONE NO.

Gemari Fatima B. Babon

Purok 1, Brgy. Canlapwas, Catbalogan City

09305718044

Miguel D. Cabidog III

Brgy. E Poblacion, Tarangnan, Samar

09275970177

Jhon Nerome Naraja

Brgy. Rizal, Daram, Samar

09771934413

44. I declare under the penalties of perjury that this Personal Data Sheet has been accomplished in good faith, verified by me and to
the best of my knowledge and belief 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 sated herein. I trust that this
information shall remain confidential.

17310499
COMMUNITY TAX CERTIFICATE NO.
MOTIONG, W. SAMAR
ISSUED AT

SIGNATURE (Sign inside the box)

02/29/16

03/10/16

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

RIGHT THUMBMARK

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