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 filled up by CSC)
I. PERSONAL INFORMATION
2. SURNAME P A L O M A
FIRST NAME R O S E M A E
MIDDLE NAME C A L I P U S A N 3. NAME EXTENSION (e.g. Jr., Sr.) N A
4. DATE OF BIRTH (mm/dd/yyyy) 01/31/1990 16. RESIDENTIAL ADDRESS
5. PLACE OF BIRTH POBLACION, SAN VICENTE, DAVAO
PUROK 2-A, POBLACION LAAK,
COMPOSTELA VALLEY
6. SEX Male Female
7. CIVIL STATUS Single Widowed ZIP CODE 8810
Married Separated 17. TELEPHONE NO. N/A
Annulled Others, specify ______________ 18. PERMANENT ADDRESS
PUROK 2-A, POBLACION LAAK,
8. CITIZENSHIP FILIPINO
COMPOSTELA VALLEY
9. HEIGHT (m) 1.5494
10. WEIGHT (kg) 41 ZIP CODE 8810
11. BLOOD TYPE B 19. TELEPHONE NO. N/A
12. GSIS ID NO. N/A 20. E-MAIL ADDRESS (if any) rosemaepaloma@yahoo.com
13. PAG-IBIG ID NO. N/A 21 CELLPHONE NO. (if any) 09265878852/09098167466
14. PHILHEALTH NO. 16-201007333-2 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. N/A 23. TIN 487-417-307
II. FAMILY BACKGROUND
24. SPOUSES SURNAME N/A 25. NAME OF CHILD (Write in full name and list all) DATE OF BIRTH (mm/dd/yy)
FIRST NAME N/A
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
(Continue on separate sheet if necessary)
26. FATHERS SURNAME PALOMA
FIRST NAME RUBEN
MIDDLE NAME USARES
27. MOTHERS MAIDEN NAME :
SURNAME CALIPUSAN
FIRST NAME LOIDA
MIDDLE NAME VERTUDAZO (Continue on separate sheet if necessary)
III. EDUCATIONAL BACKGROUND
28. HIGHEST GRADE/
YEAR INCLUSIVE DATES OF SCHOLARSHIP/
NAME OF SCHOOL DEGREE COURSE LEVEL/ ATTENDANCE
LEVEL GRADUATED ACADEMIC HONORS
(Write in full) (Write in full) UNITS EARNED
(if graduated) RECEIVED
(if not graduate) From To
LAAK SEVENTH-DAY ADVENTIST
ELEMENTARY ELEMENTARY SCHOOL
ELEMENTARY 2003 GRADUATED 1998 2003 N/A

SECONDARY LAAK NATIONAL HIGH SCHOOL SECONDARY 2007 GRADUATED 2003 2007 N/A
BACHELOR OF
LAAK INSTITUTE FOUNDATION,
COLLEGE INCORPORATED
ELEMENTARY 2012 GRADUATED 2007 2012 N/A
EDUCATION
GRADUATE STUDIES
N/A

(Continue on separate sheet if necessary)

ROSE MAE C. PALOMA Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY

29. DATE OF LICENSE (if applicable)
PLACE OF EXAMINATION /
CAREER SERVICE/RA1080 (BOARD BAR) RATING EXAMINATION/
CONFERMENT NUMBER DATE OF RELEASE
UNDER SPECIAL LAWS/ CES /CSEE CONFERMENT
UNIVERSITY OF IMMACULATE
LICENSURE EXAMINATION FOR TEACHER 75.00 MARCH 29, 2015
CONCEPCION, DAVAO CITY 1385371 08/23/2015
 (Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES SALARY GRADE
GOVT
(mm/dd/yyyy) POSITION TITLE DEPARTMENT/AGENCY/OFFICE/COMPANY MONTHLY & STEP STATUS OF
SERVICE
(Write in full) (Write in full) SALARY INCREMENT APPOINTMENT
From To (Yes / No)
(Format 00.0)
ALTERNATIVE
LEARNING SYSTEM
ALTERNATIVE LEARNING SYSTEM (ALS)
01/06/2016 10/31/2016 (ALS) ABOT-ALAM
ABOT-ALAM PROGRAM 9,500.00 CONTRACTUAL YES
VOLUNTEER
TEACHER
ALTERNATIVE
LEARNING SYSTEM
ALTERNATIVE LEARNING SYSTEM (ALS)
11/01/2015 12/31/2015 (ALS) ABOT-ALAM
ABOT-ALAM PROGRAM 4,000.00 CONTRACTUAL YES
VOLUNTEER
TEACHER
ALTERNATIVE
LEARNING SYSTEM
ALTERNATIVE LEARNING SYSTEM (ALS)
10/01/2015 10/31/2015 (ALS) ABOT-ALAM
ABOT-ALAM PROGRAM 9,500.00 CONTRACTUAL YES
VOLUNTEER
TEACHER

(Continue on separate sheet if necessary)

ROSE MAE C. PALOMA CS FORM 212 (Revised 2005) Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
31. INCLUSIVE DATES NUMBER
NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy) OF POSITION / NATURE OF WORK
(Write in full) HOURS
From To

N/A

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

32. INCLUSIVE DATES OF ATTENDANCE NUMBER
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (mm/dd/yyyy) CONDUCTED / SPONSORED BY
OF
(Write in full) (Write in full)
From To HOURS
DIVISION ALTERNATIVE LEARNING SYSTEM (ALS)
32 DEPARTMENT OF EDUCATION
GAD TRAINING AND CONNECTAYO HOLISTIC 05/17/2016 05/20/2016 HOURS
FORMATION
DIVISION ALTERNATIVE LEARNING SYSTEM (ALS)
16 DEPARTMENT OF EDUCATION
ROLLING CONFERENCE AND KUMUSTAHAN SA 11/19/2015 11/20/2015 HOURS
BARANGAY WITH LITERACY MAPPING
476 TECHNICAL EDUCATION AND SKILLS
COMPUTER HARDWARE SERVICING NC II 12/12/2011 05/10/2012 HOURS DEVELOPMENT AUTHORITY

(Continue on separate sheet if necessary)

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

ENCODING N/A N/A

MAKING ARTS

DRAWING

(Continue on separate sheet if necessary)

ROSE MAE C. PALOMA 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 you will be appointed?
if YES, give details:
__________________________________
__________________________________
__________________________________
37. YES NO
a. Have you ever been formally charge?
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 local election (except Barangay election)? YES NO
if YES, give details:
__________________________________
__________________________________
41. 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:

YES NO
a. Are you a member of any indigenous group? 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.

FRONTERAS, LEVI M. MACO, COMPOSTELA VALLEY 09161037314

CLAREON, ELVIE S. POBLACION LAAK, COMPOSTELA VALLEY 09778016765
HULGUIN, PERLIE GRACE P. POBLACION LAAK, COMPOSTELA VALLEY 09161851304
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.

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

02707918
COMMUNITY TAX CERTIFICATE NO. ID picture taken within
the last 6 months
3.5 cm. x 4.5 cm
LAAK, COMPOSTELA VALLEY (passport size)
ISSUED AT SIGNATURE (Sign inside the box)
Computer generated
01/11/2016 11/15/2016 or xerox copy of picture
Is not acceptable
ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED

ROSE MAE C. PALOMA CS FORM 212 (Revised

PHOTO 2005) Page 4 of 4

RIGHT THUMBMARK