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

I. PERSONAL INFORMATION
2. SURNAME S | I | A| C | O | R | | | | | | | | | | | | | | | | | | | | |

FIRST NAME J| O | C | E | L | Y |N | | | | | | | | | | | | | | | | |

MIDDLE NAME Y | U |N | T | I |N |G | | | | | | | | | | 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS
4. DATE OF BIRTH (mm/dd/yyyy) 07/25/1972
5. PLACE OF BIRTH Bayawan City, Negros Oriental NANGKA , BAYAWAN CITY, NEGROS ORIENTAL
6. SEX Male Female
7. CIVIL STATUS
Single Widowed ZIP CODE 6221
Married Separated Annulled 17. TELEPHONE NO.

___________Others, specify18. PERMANENT ADDRESS

8. CITIZENSHIP Filipino NANGKA , BAYAWAN CITY, NEGROS ORIENTAL

9. HEIGHT (m) 1.58
10. WEIGHT (kg) 55.6 kgs. ZIP CODE 6221
11. BLOOD TYPE A+ 19. TELEPHONE NO. none
12. GSIS ID NO. B72PRJYSO12 20. E-MAIL ADDRESS (if any) Jocelynsiacor@yahoo.com
13. PAG-IBIG ID NO. 0701-647375-09 21. CELLPHONE NO. (if any) 09278322655
14. PHILHEALTH NO. 12-000072803-4 22. AGENCY EMPLOYEE NO. 7960369
15. SSS NO. N/A 23. TIN 910-896-369
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME SIACOR 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH

FIRST NAME EMEZALDE JO-EM Y. SIACOR 05/31/

MIDDLE NA BACALLA PRINCESS EMEJOY Y. SIACOR 03/30/
OCCUPATION FIELD COORDINATOR JEMZ CARL Y. SIACOR 07/19/
EMPLOYER/BUS. NAME LGU-BAYAWAN CITY N/A N/A
BUSINESS ADDRESS Bayawan City, Negros Oriental N/A N/A
TELEPHONE NO. N/A N/A
(Continue on separate sheet if necessary) N/A N/A
26. FATHER'S SURNAME YUNTING N/A N/A
FIRST NAME MAGDALENO N/A N/A
MIDDLE NAME OMOYON N/A N/A
27. MOTHER'S MAIDEN NAME N/A N/A
SURNAME NARIO N/A N/A
FIRST NAME JULIA N/A N/A
MIDDLE NAME ANSOK (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND YEAR

GRADUATED
HIGHEST GRADE/ INCLUSIVE DATES OF
28. NAME OF SCHOOL
DEGREE COURSE LEVEL/ ATTENDANCE
LEVEL
(Write in full) UNITS EARNED
(Write in full)
(if not graduated) From To

(if graduated) March

ELEMENTARY NANGKA ELEMENTARY SCHOOL N/A 1985 N/A June 1979
1985
NEGROS ORIENTAL NATIONAL HIGH March
SECONDARY
VOCATIONAL / SCHOOL N/A 1989 N/A June 1985
1989
NEGROS ORIENTAL NATIONAL HIGH
BAT 1992 N/A 1989 1992
SCHOOL
COLLEGE
TRADE COURSE
NEGROS ORIENTAL STATE Bachelor of Science in March
Industrial Education
2003 N/A June 1998
UNIVERSITY 2003
Certificate Program
CEBU NORMAL UNIVERSITY in MAPEH
2009 N/A April 2008 May 2009
 N/A N/A N/A N/A N/A N/A
GRADUATE STUDIES
NEGROS ORIENTAL STATE
MAEM N/A 21 1995 1998
UNIVERSITY

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

(Continue on separate sheet if necessary)

L DATA SHEET
(to be filled up by CSC)

| | | | | | | | | | | | | |

| | | | | | | | | | | | | | |

NANGKA , BAYAWAN CITY, NEGROS ORIENTAL

6221

NANGKA , BAYAWAN CITY, NEGROS ORIENTAL

6221
none
Jocelynsiacor@yahoo.com
09278322655
7960369
910-896-369

DATE OF BIRTH (mm/dd/yyyy)

05/31/1999
03/30/2005
07/19/2006
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC HONORS
RECEIVED

N/A

N/A

N/A

N/A

N/A
 N/A

N/A

N/A

eparate sheet if necessary)

Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29. DATE OF LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE NUMBER DATE OF
CONFERMENT
RELEASE
Negros Oriental High School,
Licensure Examination for Teachers (LET) 7.00% 05/23/1995 0567046 7/25/95
Dumaguete City
N/A N/A N/A N/A N/A N/A

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(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work) GOV'T
SERVICE
30. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SALARY GRADE
(mm/dd/yyyy) MONTHLY & STEP STATUS OF
SALARY INCREMENT APPOINTMENT
(Write in full) (Write in full) (Format "00-0")
From To
(Yes / No)
08/22/1996 12/31/1996 Secondary School Teacher I Kalumboyan High School 6,013.00 STEP 1 Permanent Yes

01/01/1997 10/31/1997 Secondary School Teacher I Kalumboyan High School 7,309.00 STEP 1 Permanent Yes

11/01/1997 08/21/1999 Secondary School Teacher I Kalumboyan High School 8,605.00 STEP2 Permanent Yes

01/01/2000 06/30/2001 Secondary School Teacher I Kalumboyan High School 9,703.00 STEP2 Permanent Yes

07/01/2001 08/21/2002 Secondary School Teacher I Kalumboyan High School 10,188.00 STEP3 Permanent Yes

08/22/2002 08/21/2005 Secondary School Teacher I Kalumboyan High School 10,442.00 STEP4 Permanent Yes

08/22/2005 06/30/2007 Secondary School Teacher I Bayawan National High School 10,704.00 step4 Permanent Yes

07/01/2008 08/21/2008 Secondary School Teacher I Bayawan National High School 12,951.00 step5 Permanent Yes

08/21/2008 08/21/2011 Secondary School Teacher I Bayawan National High School 16,687.00 STEP6 Permanent Yes

08/21/2011 08/21/2014 Secondary School Teacher I Bayawan National High School 18,227.00 STEP7 Permanent Yes

08/21/2016 PRESENT Secondary School Teacher I Bayawan National High School 21,650.00 STEP7 Permanent Yes

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

None 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

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(Continue on separate sheet if necessary)

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

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

Mass Training of Public Secondary Teachers 05/18/2000 05/19/2000 16hrs Deped.Negros Oriental

Grade 10 K-12 Training and Workshop 05/11/2015 05/16/2015 48 hrs. Deped, Negros-Siquijor Province

Training of Grade 8 TLE Teachers in K to 12 Basic Educ.

Curriculum
05/20/2013 05/24/2013 54 hrs Deped Cebu Technology University

Certificate Program for Non- Specialist Teachers in Music,

04/14/2009 05/26/2009 284 hrs Cebu Normal University
Arts, Physical Education & Health (MAPEH)

Seminar-workshop on Coaching in the different Selected

events to capacitate teachers/coaches with the knowledge 08/22/2014 08/23/2014 16 hrs Banga Central School
and skills needed in coaching.

Summer Sports Clinic for Football/Futsal 04/18/2016 04/23/2016 48 hrs. Bayawan East

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(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Computer Literacy N/A Parents Teachers Association

Cooking N/A

N/A N/A N/A

N/A N/A N/A

(Continue on separate sheet if necessary)
CS FORM 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): YES NO

appointing authority, recommending authority, chief of office/bureau/department or person who If YES, give details:
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): 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.

Andrito Q. Bajardo Villareal, Bayawan City ID picture taken within

the last 6 months
Adonis S. Rivera Poblacion ,Bayawan City 3.5 cm. X 4.5 cm
(passport size)
Christine Lorraine T. Tijing Amparos Village,Villareal, Bayawan City
Computer generated
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and or xerox copy of picture
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable

Philippines.

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

37172075
COMMUNITY TAX CERTIFICATE NO.
Villareal, Bayawan City
ISSUED AT SIGNATURE (Sign inside the box)

01/12/2017
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

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

If YES, give details:
_____________________________________
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_____________________________________

If YES, give details:

_____________________________________
_____________________________________
_____________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, give details:

________________________________
________________________________

If YES, please specify: ____________________

If YES, please specify: ____________________

If YES, please specify: ____________________

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