Documente Academic
Documente Profesional
Documente Cultură
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME SAZ
NAME EXTENSION (JR., SR)
FIRST NAME ROVIE
MIDDLE NAME SAZ
3. DATE OF BIRTH
16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy) 8/181988 ✘
by
by naturalization
birth
4. PLACE OF BIRTH BADONG, TAGO, SURIGAO DEL SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female
15. AGENCY EMPLOYEE NO. L7200261 21. E-MAIL ADDRESS (if any) sazroviegalagar@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
VOCATIONAL /
SECONDARY BADONG NATIONAL HIGH SCHOOL 6/1/2002 3/1/2005 2005
SURIGAO DEL SUR STATE UNIVERSITY ASSOCIATE COMPUTER TECHNOLOGY 6/1/2005 3/30/2006 21 UNITS
06/13/2016 PRESENT SENIOR HIGH SCHOOL TEACHER II LINGIG NATIONAL HIGH SCHOOL 22,938 N/A
NUMBER Date of
Validity
10608112 6/13/2016
ption of duties should be indicated in the attached Work Experience sheet. GOV'T
SERVICE
STATUS OF
APPOINTMENT
(Y/
N)
PERMANENT Y
VOLUNTER Y
ue on separate sheet if necessary)
IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/5/2019 4/28/2019 VACATION CHURCH
IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/3/2018 4/30/2018 VACATION CHURCH
IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/1/2017 4/31/2017 VACATION CHURCH
IGLESIA FILIPINA INDEPENDENTE CHURCH (BADONG, TAGO, S.D.S.) 4/20/2016 4/23/2016 VACATION CHURCH
DISTRICT ROLL-OUT ON LRMS MECHANISM AND FRAMEWORK 12/6/2018 12/6/2018 9 HRS. DEPED LI
BRGY. DR
THREE DAYS BASIC LIFE SUPPORT TRAINING 6/28/2018 6/30/2018 18 HRS.
BUREAU O
BNHS (BADON
COMPUTER LITERATE N/A
ALUM
SIGNATURE DATE J
ENT / PEOPLE / VOLUNTARY ORGANIZATION/S
CONDUCTED/ SPONSORED BY
(Write in full)
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:
36. 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:
________________________________
________________________________
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 If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year YES ✘ NO
(except Barangay election)? If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country? YES ✘ NO
If YES, give details (country):
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:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:
41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)
NAME ADDRESS TEL. NO.
ID picture taken within
the last 6 months
WILLY C. DUMPIT, PhD, FRIdr SCHOOL HEAD, LINGIG NHS 9999666393 3.5 cm. X 4.5 cm
(passport size)
LOURDES O. ORCULLO, EdD PRINCIPAL III, MANDUS NHS 9552997755 With full and handwritten
name tag and signature over
printed name
ALAN S. TIONGSON SHS-ASS. SCHOOL HEAD LNHS 9489726609
Computer generated
42. or photocopied picture
is not acceptable
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering Oath
CS FORM 212 (Revised 2017), Page 4 o
If YES, give details (country):