CS FORM 212 (Revised 2005)

PERSONAL DATA SHEET

1. CS ID NO.
(To be filled up by CSC)

Print legibly, Mark appropriate boxes

I. PERSONAL INFORMATION
2. SURNAME
B A L
FIRST NAME
N O E
4.
5.
6.
7.

MIDDLE NAME
DATE OF BIRTH
PLACE OF BIRTH
SEX
CIVIL STATUS

A N G
M E

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

M E
N D O Z A
(MM/DD/YY)
04/29/1959
BAKUN BENGUET
Male
/ Female
16. RESIDENTIAL ADDRESS
Single
Widowed
/

Married

Separate
d
Others,
specify

annulled
8. CITIZENSHIP
9. HEIGHT (M)
10. WEIGHT (kg)
11. BLOOD TYPE
12. GSIS ID NO.
13. PAG-IBIG ID NO.

FILIPINO
150
56 kg.
B
B59HVNMB017

MIDDLE NAME
OCCUPATION

25. NAME OF CHILD

LILIA BALANGEG
SAGUIBAL
MARVIN MENDOZA
BALANGEG
MELISSA MENDOZA
BALANGEG
MARIA TERESA MENDOZA
BALANGEG

BUSINESS ADDRESS
TELEPHONE NO.
26. FATHERS SURNAME
FIRST NAME
MIDDLE NAME
27. MOTHERS MAIDEN
NAME
SURNAME
FIRST NAME
MIDDLE NAME

N/A

N E

NONE
BAO-EDAN, DALIPEY
BAKUN, BENGUET
2610
NONE
NONE
09089889939

22. AGENCY EMPLOYEE

NO.
23. TIN

FARMER

EMPLOYEE/BUS.NAME

17. TELEPHONE NO.

ZIP CODE
19. TELEPHONE NO.
20. E-MAIL ADDRESS
21. CELL PHONE NO.

DULAG

KF-32 CRUZ
LA TRINIDAD
BENGUET
2601

ZIP CODE

18. PERMANENT ADDRESS

010123338706
14. PHIL HEALTH
04NO.
000025482-9
15. SSS NO.
N/A
II. FAMILY BACKGROUND
24. SPOUSES SURNAME
BALANGEG
FIRST NAME
PRIMO

4115771
187-261-965
DATE OF BIRTH
04-24-1999
03-26-1983
03-20-1987
10-09-1990

N/A
NONE
MENDOZA
(deceased)
NELSON
ABIASAN
TALUYOD
MENDOZA
COTLAGING
TOG-AK
Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

28. LEVEL
NAME OF SCHOOL
(Write in full)

DEGREE
COURSE
(Write in full)

YEAR
GRADUATED
(if
graduat
ed

HIGHEST
GRADE
LEVEL
UNITS (If
not
grad.)

INCLUSIVE
DATE OF
ATTENDANC
E
FR0
TO
M

196
6

1972

1972

GRADUATED

ACADEM
IC
HONOR
S
RECEIVE
D
N/A

1976

GRADUATED

197
2

1976

N/A

N/A

N/A

N/A

N/A

N/A

ELEMENTARY
PALIDAN ELEMENTARY
SCHOOL
SECONDARY
VOCATIONAL/
TRADE
COURSE

BENGUET PROVINCIAL
HIGH SCHOOL
N/A

ELEMENTAR
Y
HIGH
SCHOOL
N/A

SCHOLA
RSHIP

COLLEGE

GRADUATE
STUDIES

BENGUET STATE
UNIVERSITY

BS
FORESTRY

BAGUIO CENTRAL
UNIVERSITY
BAGUIO CENTRAL
UNIVERSITY

BEED
MA. Ed

1981

GRADUATED

197
6

GRADUATED

198
5
199
4

1991
1999

(Continue on separate sheet if necessary)

BALANGEG

PBET

N/A

1991

N/A

1999

N/A

NOEME M.
CS FORM

212 (REVISED 2005), Page 1 0f 4 pages

IV. CIVIL SERVICE ELIGIBILITY
29. CAREER SERVICE RA 10890
(BOARD/ BAR UNDER SPECIAL
LAWS/CES/CSEE

1981

RATING

DATE OF
EXAMINATION
/
COFERMENT

PLACE OF
EXAMINATION/
CONFERMENT

71.61

10/25/1992

BAGUIO CITY

LICENSE (if
applicable)
NUMBE
DATE
R
PRC
RELEASED
03853
06/13/92
73

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES
POSITION
DEPARTMENT/AGENC
Monthly
SALARY
STATU
TITLE
Y
S
(MM/DD/YY)
(Write in full)
OFFICE/COMPANY
Salary
GRADE &
OF
(Write in full)
FROM
07/01/20
07
06/06/20
05
04/14/20
04
02/01/19
99
YES06/17
/1993
02/01/19
92
10/21/19
92
05/01/19
85

TO
PRESENT
06/30/200
7
06/05/200
5
06/13/200
4
01/31/199
9
03/15/199
2
12/01/199
2
10/01/199
1

SCHOOL
PRINCIPAL
HEAD
TEACHER III
TEACHER III
TEACHER II
TEACHER I
ENUMERATOR
PROJECT
INSPECTOR
LOGGING
SUPERVISOR

DEPARTMENT OF
EDUCATION
DEPARTMENT OF
EDUCATION
DEPARTMENT OF
EDUCATION
DEPARTMENT OF
EDUCATION
DEPARTMENT OF
EDUCATION
NATIONAL STATISTICS
OFFICE.
BSU-DEVELOPMENT
FOUNDATION INC
LEPANTO MINING
COMPANY

STEP

APPOI
NT
MENT

GOVT
SERVIC
E
(YES/

30, 880

(10-07)
SG-19

13, 300

SG-15

PERMANE
NT

YES

11, 167

SG-12

PERMANE
NT

YES

9, 121

SG-11

PERMANE
NT

YES

3, 902

SG-10

PERMANE
NT

YES

3, 000

N/A

CONTACTUAL

YES

4, 000

N/A

CONTACTUAL

NO

4, 500

N/A

CONTACTUAL

NO

PERMANE
NT

NO)
YES

(Continue on separate sheet if necessary)

NOEME M.
BALANGEG
CS FORM 212 (Revised

2005), Page 2 of 4 pages

V. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC-GOVERNMENT/PEOPLE/VOLUNTARY

ORGANIZATIONS
31. NAME & ADDRESS OF
INCLUSIVE DATES
NUMBER
POSITION/ NATURE OF WORK
ORGANIZATION
(MM/DD/YYYY)
OF
(Write in full)
FROM
TO
HOURS
CHRISTIAN WOMENS
01/08/19 PRESEN
N/A
MEMBER
ORGANIZATION/ASSOCIATION
93
T
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (START FROM THE MOST RECENT TRAINING)
32. TITLE OF SEMINARS/CONFERENCE
INCLUSIVE DATES
WORKSHOP/SHORT COURSES
(MM/DD/YYYY)
NUMBER
(Write in full)
OF
HOURS
FROM
TO
Educators forum on personnel administration.
06/03/
8
2011
Pre- planning workshop on school improvement
03/22/201 03/22/201
16
plan (SIP)
1
1
Echo seminar-workshop on action research,
09/16/201 09/19/201
24
strategic intervention and strategies in science
0
0
teaching.
5th- SECID- PSERT Annual national educational
04/26/201 04/30/201
40
management training seminar.
0
0
Mass training for Elementary teachers on English
05/31/201 06/04/201
40
language and reading enhancement program.
0
0
Training on operationalization of experimental
03/15/201 03/17/201
24
learning course and other administrative matter.
0
0
Division seminar-workshop in the enhancement of
09/21/200 09/23/200
24
pre-school teaching.
9
9
Trainers training on eight week curriculum for
09/12/200 09/16/200
40
school heads.
9
9
Trainers training and workshop for dance sports
05/27/200 05/29/200
24
adjudicators and scruiteners.
9
9
Seminar on creative problem intervention for
07/09/200 07/11/200
24
school administrators at the field level.
9
9
School improvement plan (SIP) Training workshop.
05/12/200 05/16/200
24
8
8
School management information system (SMIS)
12/14/200
8
roll-out.
7
National English proficiency program.
05/21/200 05/23/200
24
7
7
Information and communication technology
08/28/200 08/30/200
24
leadership training program for school head.
6
6
Training on the utilization of Q- LEARN packages.
05/29/006 05/31/200
24
6
National training workshop on current trends on
11/30/200 12/06/200
24
alternative learning system for public schools
5
5
district supervisors.

CONDUCTED/
SPONSORED BY
CSC-CAR
DepEd Division
DepEd District
National- SECID
DepEd District
DepEd Division
DepEd Division
DepEd Division
DepEd Division
DepEd Division
DepEd Division
DepEd Division
DepEd Division
DepEd Regional
DepEd Division
National

VIII. OTHER INFORMATION

33. SPECIAL
34. NON-ACADEMIC DISTINCTIONS/
SKILLS/
RECOGNITIONS (Write in full)
HOBBIES
COOKING
GOLD SERVICE AWARD-BSP
GARDENING

35. MEMBERSHIP IN ASSOCIATION/

ORGANIZATION (Write in full)

SILVER SERVICE AWARD-BSP

BRONZE MEDAL AWARD-BSP

BENGUET PUBLIC SCHOOL TEACHERS

ASSOCIATION
PARENTS TEACHERS ASSOCIATION

( continue on separate sheet if necessary)

NOEME M. BALANGEG
CS FORM

212 ( Revised 2005), Page 3 of 4 pages

36. Are you related by consanguinity or affinity to any of the following

a. Within the third degree(for national Government Employee)
appointing authority, recommending authority, chief of office
YES
NO
bureau/department or person who has immediate supervision
If yes, give details
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 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 even guilty of any administrative offense?
YES

NO

_________________
38. Have you been convicted of any crime or violation
YES
/
NO
of any law, decree, ordinance or regulation by any court or tribunal ?
If yes, give details
____________________
39. Have you been separated from the service in any of the following
Modes: resignation, retirement, dropped from the rolls, dismissal, termination,
YES
/
NO
End of term, finished contract, AWOL, or phased out, in the public or private sector?
If yes, give details
40. Have you ever been candidate in national or local election?
YES
If yes, give details
_________________

/
NO
(except Barangay Election)

41. Pursuant to:(a) Indigenous Peoples Act (RA 8371);

YES
/
NO
(b) Magna Carta for Disabled Persons, (RA 7277)
If yes, give details
& (c) Solo Parents Welfare Act of 2000(RA 8972)
_________________
Please answer the following items:
A. Are you a member of any abled?
YES

NO

If yes, give details

__________________
B. Are you differently abled?
YES

NO

If yes, give details

_________________
C. Are you a solo parent?
YES

NO

If yes, give details

42. REFERENCES (Persons not related by consanguinity or affinity to applicant/appointee
NAME
ADDRESS
CELL PHONE NUMBER
CAMILO T. COMPAS
DALIPEY, BAKUN, BENGUET
09202805603
DAVID A. ABYADANG
AMPUSONGAN, BAKUN, BENGUET
09398547262
LORENZO G. SANTIBAN
DALIPEY, BAKUN, BENGUET
09107308977
43. I declare under oath that this personal data sheet has been accomplished by me,
and is true, correct and complete statement pursuant to the provisions of patent
ID picture taken
laws, rules and regulations of the Republic of the Philippines.
I also authorized the agency head/authorized representative to verify/
Validate the contents stated herein.
I trust that this information shall remain confidential.

12476415
COMMUNITY TAX CERTIFICATE NO.

BAKUN
ISSUED AT

01/05/2011

with in the last

six months
3.5 cm. x 4.5 cm.

Computer
generated or
Xerox copy of
SIGNATURE(Sign inside picture
the box)is not
JUNE 21, 2011
DATE ACCOMPLISHED

RIGHT
THUMB MARK

ISSUED ON (MM/DD/YYYY)

CS FORM 212 (Revised 2005), page 4 of

pages 4