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CS Form No.

212
Revised 2017

PERSONAL DATA SHEET


WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s aga
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do

I. PERSONAL INFORMATION
2. SURNAME NAVARRETE

FIRST NAME RICHEL JOY

MIDDLE NAME NACURAY


3. DATE OF BIRTH
APRIL 30, 1993 16. CITIZENSHIP
Dual Citizenship
(mm/dd/yyyy) Filipino
by birth by
4. PLACE OF BIRTH LIBACAO, AKLAN If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS
Single Married 17. RESIDENTIAL ADDRESS ROXAS
Widowed Separated House/Block/Lot No. S

Other/s:
POBL
Subdivision/Village Bar
7. HEIGHT (m) 5'3 ft LIBACAO AK
City/Municipality Pro
8. WEIGHT (kg) 43 kg ZIP CODE 5602

9. BLOOD TYPE "A"


18. PERMANENT ADDRESS ROXAS
House/Block/Lot No. S
POBL
10. GSIS ID NO. none
Subdivision/Village Bar
LIBACAO
11. PAG-IBIG ID NO. none
City/Municipality Pro
12. PHILHEALTH NO. none ZIP CODE 5602

13. SSS NO. 0729896100 19. TELEPHONE NO. N/A

14. TIN NO. 472-116-014-000 20. MOBILE NO. 09300745253

15. AGENCY EMPLOYEE NO. none 21. E-MAIL ADDRESS (if any) richeljoynavarrete1993@gmail
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)

FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME NAVARRETE

FIRST NAME ROBERT

MIDDLE NAME ZAPICO

25. MOTHER'S MAIDEN NAME JEANETTE NACURAY

SURNAME NAVARRETE

FIRST NAME JEANETTE

MIDDLE NAME NACURAY (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND


NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY LOCTUGA ELEMENTARY SCHOOL ELEMENTARY 1999 2005 N/A

LIBACAO NATIONAL FORESTRY


SECONDARY SECONDARY 2005 2009 N/A
VOCATIONAL HIGH SCHOOL
TRADE
COLLEGE AKLAN STATE UNIVERSITY BSBIOLOGY 2009 2013
COURSE

GRADUATE STUDIES AKLAN STATE UNIVERSITY MAED June 2016 Oct. 2016

(Continue on separate sheet if necessary)


SIGNATURE DATE 4/30/2017 CS FORM 212 (Rev
L DATA SHEET
rience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.


(Do not fill up. For CSC use only)

Dual Citizenship

by naturalization

Pls. indicate country:

ROXAS STREET
Street
POBLACION
Barangay
AKLAN
Province
5602

ROXAS STREET
Street
POBLACION
Barangay
AKLAN
Province

N/A

09300745253

richeljoynavarrete1993@gmail.com

DATE OF BIRTH
(mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2005

HONORABLE
2009 MENTION
arate sheet if necessary)
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
LICENSURE EXAMINATION FOR TEACHERS
79.0 1/3/2016 ILOILO, CITY 2743404 4/30/2020
(LET)

(Continue on separate sheet if necessary)


V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet. GOV'T
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To (Y/
N)
LIBACAO COLLEGE OF SCIENCE AND
8/1/2014 PRESENT COLLEGE INSTUCTOR 5,000.00 CONTRACTUAL YES
TECHNOLOGY
ONLINE ENGLISH TUTOR FOR
6/1/2015 PRESENT 51 TALK NOT FIXED PART-TIME N/A
CHINESE STUDENT
ONLINE ENGLISH TUTOR FOR
4/1/2013 4/1/2014 PIKT NOT FIXED PART-TIME N/A
JAPANESE STUDENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 4/30/2017 CS FORM 212 (Revised 2017), Page 2 of 4


VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / N
From To

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

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED


(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SP
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

PERFORMANCE MANAGEMENT SYSTEM 01/28/2015 01/29/2015 MUNICIPAL L

COMMUNITY COLLEGE LEADERSHIP TRAINING FOR TEACHERS 9/3/2014 9/4/2014

ONBOARD TRAINING FOR NEW TEACHER 8/4/2014 8/5/2014

ICT INTEGRATION IN LESSON 7/16/2014 7/18/2014

BASIC BUSINESS MANAGEMENT TRAINING 1/7/2013 7/31/2013 PM

SEMINAR WORKSHOP ON DANCE FORMS & THEATER ARTS 2/3/2011 2/5/2011 AKLA

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
Resource Speaker N/A

COACH

MASTEROF CEREMONY

TABULATORS

LEADERSHIP

FACILITATOR
(Continue on separate sheet if necessary)

SIGNATURE DATE 04/18/17


EOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

N/A

te sheet if necessary)

GRAMS ATTENDED
(5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

MUNICIPAL LOCAL GOVERNMENT LIBACAO

LCST

LCST

LCST

PM SOLUTION, JAPAN

AKLAN STATE UNIVERSITY

te sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION

(Write in full)
DEPED

LCST

LCST

LGU

SSG

LCST
te sheet if necessary)

CS FORM 212 (Revised 2017), Page 3 of 4


34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES NO
If YES, give details:
________________________________
N/A

35. a. Have you ever been found guilty of any administrative offense? YES NO
If YES, give details:
________________________________
N/A
________________________________
b. Have you been criminally charged before any court? YES NO
If YES, give details:
________________________________
Date Filed: N/A
________________________________
Status of Case/s: N/A

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation NO
YES
by any court or tribunal?
If YES, give details:
________________________________
N/A
________________________________
37. 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 or phased If YES, give details:
out (abolition) in the public or private sector? ________________________________
N/A
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except YES NO
Barangay election)?
If YES, give details: N/A

b. Have you resigned from the government service during the three (3)-month period before the last YES NO
election to promote/actively campaign for a national or local candidate? If YES, give details: N/A
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES NO
If YES, give details (country):
N/A
40. 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: AKEANON BUKIDNON
b. Are you a person with disability? YES NO
If YES, please specify ID No: N/A
c. Are you a solo parent? YES NO
If YES, please specify ID No: N/A

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

NAME ADDRESS TEL. NO.


ID picture taken within
the last 6 months
Hon. Charito I. Navarosa Municipal Local Government Libacao 3.5 cm. X 4.5 cm
(passport size)

Dr. Stephanie S. Pimentel Capiz State University With full and handwritten
name tag and signature over
printed name
Dr. Marivel Z. Villorente Aklan State University
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines. I authorize the agency head / authorized representative to verify/validate the contents stated herein. I
agree that any misrepresentation made in this document and its attachments shall cause the filing of PHOTO
administrative/criminal case/s against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)


PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID: Professional Identification Card

ID/License/Passport No.: 2743404 Signature (Sign inside the box)


04/30/2017
Date/Place of Issuance: 1/10/2017
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

CHARITO I. NAVAROSA
Municipal Mayor

CS FORM 212 (Revised 2017), Page 4 of


If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4