CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET

Print legibly. Mark appropriate boxes

with "

T15097794

1. CS ID No.

" and use separate sheet if necessary.

(to be filled up by CSC)

I. PERSONAL INFORMATION
STA ANA

2. SURNAME
FIRST NAME

BEVERLY

MIDDLE NAME

MACARAIG

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

11 / 06 / 1988

4. DATE OF BIRTH (mm/dd/yyyy)

16. RESIDENTIAL ADDRESS

Obando Bulacan

5. PLACE OF BIRTH

MALE

6. SEX

#15 Mangga St. Bilog Balangkas, CITY OF

VALENZUELA, NCR THIRD DISTRICT

FEMALE

7. CIVIL STATUS

ZIP CODE

Single

Widowed

Married

Separated

Annuled

Others, specify
_________

1445

17. TELEPHONE NO.

432-05-25

18. PERMANENT ADDRESS

#15 Mangga St. Bilog Balangkas, CITY OF

VALENZUELA, NCR THIRD DISTRICT

8. CITIZENDSHIP

filipino

9. HEIGHT (m)

157.48

10. WEIGHT (kg)

100

11. BLOOD TYPE

A+

19. TELEPHONE NO.

432-05-25

12. GSIS ID NO.

N\A

20. EMAIL ADDRESS (if any)

beverlystaana@gmail.com

13. PAGIBIG ID NO.

N\A

21. CELLPHONE NO. (if any)

09164662913

14. PHILHEALTH NO.

N\A

22. AGENCY EMPLOYEE NO.

N\A

15. SSS NO.

34-1432630-6

23. TIN

457-420-359

ZIP CODE

1445

II. FAMILY BACKGROUND

25. NAME OF CHILD (Write full name and list all)

24. SPOUSE'S SURNAME

DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
(Continue on separate sheet if necessary)

Sta Ana

26. FATHER'S SURNAME

FIRST NAME

Carlos

MIDDLE NAME

Martin

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME

Francisco

FIRST NAME

Victoria

MIDDLE NAME

Macaraig

III. EDUCATIONAL BACKGROUND

LEVEL

NAME OF SCHOOL
(Write in full)

DEGREE COURSE
(Write in full)

YEAR
GRADUATED
(if graduated)

HIGHEST
GRADE/
LEVEL/ UNITS
EARNED
(if not
graduated)

INCLUSIVE DATES OF
ATTENDANCE

From

To

SCHOLARSHIP/ ACADEMIC
HONORS RECEIVED

ELEMENTARY

Obando Central School

2001

1995

2001

N/A

SECONDARY

Obando School Of Fisheries

2005

2001

2005

N/A

VOCATIONAL/ TRADE
COURSE

N/A

COLLEGE

City University Of Pasay

GRADUATE STUDIES

N\A

N/A

N/A

Bachelor Of Science
Secondary Education

2013

N\A

N\A

2009

N\A

N\A

N/A

2013

N\A

N\A

IV. CIVIL SERVICE ELIGIBILITY

STA ANA, BEVERLY MACARAIG - T15097794

CS FORM 212 (Revised 2005), Page 1 of 3

29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
UNDER SPECIAL LAWS/ CES/ CSEE

LET (LICENSURE EXAMINATION FOR

TEACHER)

LICENSE (if applicable)

DATE OF
EXAMINATION /
CONFERMENT

RATING

77.80

PLACE OF EXAMINATION / CONFERMENT

DATE OF
RELEASE

NUMBER

08 / 27 / 2014

Manila

1341010

01/01/1970

V. WORK EXPERIENCE
30.

INCLUSIVE DATES
(mm/dd/yyyy)
From

To

05/16/2015

01/18/2016

POSITION TITLE (Write in full)

DEPARTMENT / AGENCY / OFFICE /

COMPANY (Write in full)

MONTHLY
SALARY

SALARY
GRADE &
STEP
INCREMENT
(Format "00-0")

STATUS OF
APPOINTMENT

GOV'T SERVICE
(Yes / No)

HIGH SCHOOL TEACHER (Science)

PATNUBAY ACADEMY

10,000

0-0

Regular

No

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

31.

INCLUSIVE DATES
(mm/dd/yyyy)

NAME & ADDRESS OF ORGANIZATION

(Write in full)

N/A

From

To

N/A

N/A

NUMBER OF
HOURS

POSITION / NATURE OF WORK

N/A

N/A

NUMBER OF
HOURS

CONDUCTED/ SPONSORED BY
(Write in full)

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

32.
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES
(Write in full)

INCLUSIVE DATES OF
ATTENDANCE
(mm/dd/yyyy)
From

To

Prepress Operation Training Course (Visual Graphics Operation NCIII)

02 / 22 / 2016

04 / 28 / 2016

200

VALUES INTERGRATION SEMINAR: I TEACH, THEREFORE I AM

02 / 17 / 2016

02 / 17 / 2016

PNU: FACULTY OF
BEHAVIORAL AND SOCIAL
SCIENCES VALUES
EDUCATION PROGRAM

TEACH( TEACH, EMPOWER, ADVOCATE for CHANGE)

12 / 12 / 2015

12 / 12 / 2015

ROTARY INTERNATIONAL
DISTRICT 3810- PHILIPPINES

THE INNOVATIONS AND TRANSFORMATIONS IN THE K TO 12 BASIC

EDUCATION CURRICULUM

11 / 07 / 2015

11 / 07 / 2015

JO-ES PUBLISHING HOUSE,

INC

2ND JAPAN EDUCATION FAIR AND CONVENTION

09 / 12 / 2015

09 / 12 / 2015

JELLY FISH CONSULTANCY

PHILIPPINES, INC

COMPUTER HARDWARE SERVICING

12 / 04 / 2014

05 / 31 / 2015

216

K-12 METHODOLOGY IN THE PHILIPPINES

09 / 01 / 2013

09 / 01 / 2013

SMART through PROGRAM

RISE( RESPONSIVE
INSTRUCTIONAL SKILLS
ENHANCEMENT)

EDUCATION TECHNOOGY: A NEW PERSPECTIVE

08 / 18 / 2013

08 / 18 / 2013

SYSTEMATIC MODERN
APPROACH ON REVIEW
TECHNIQUES FOR TEACHERS
(SMART)

Philippine Graphics and Prints

(Training Center Inc.)

CAYETANO ARELLANO
EVENING VOCATIONAL
SCHOOL

VIII. OTHER INFORMATION

33.

34.
SPECIAL SKILLS / HOBBIES:

NON-ACADEMIC DISTINCTIONS / RECOGNITION:

(Write in full)

35.

MEMBERSHIP IN ASSOCIATION /
ORGANIZATION
(Write in full)

Performing clerical work

N/A

N/A

Adaptability & Flexibility

N/A

N/A

Computer/Technical Literacy

N/A

N/A

STA ANA, BEVERLY MACARAIG - T15097794

CS FORM 212 (Revised 2005), Page 2 of 3

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

a. Within the third degree (for National Government Employees):

appointing authority, recommending authority, chief of office/bureau/department or person who
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):

appointing authority or recommending authority where you will be appointed?

YES

NO

If YES, give details:

N/A

YES

NO

If YES, give details:

N/A

37. a. Have you ever been formally charged?

YES

NO

If YES, give details:

N/A
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
regulation by any court or tribunal?

39. Have you ever been separated from the service in any of the following modes: resignation,
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract, AWOL
or phased out, in the public or private sector?

YES

NO

If YES, give details:

N/A
YES

NO

If YES, give details:

N/A

40. Have you ever been a candidate in a national or local election (except Barangay election)?

YES

NO

If YES, give details:

N/A
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:N/A

b. Are you differently abled?

YES

NO

If YES, please specify:N/A

c. Are you a solo parent?

YES

NO

If YES, please specify:N/A

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

ADDRESS

TEL. NO.

Rosemarie B. Santos

312 Taylo St. Pasay City

09328864579

Rowena R. Remoroza

171 Purok 3 Rosal St. Filrizan Subd.

Bayanan, Muntinlupa City
2129F Kusang loob St. Sta Cruz Manila

09194298427

Eschanseth N. Maceda

09204759851

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.

X
PHOTO

13887730
COMMUNITY TAX CERTIFICATE NO.
VALENZUELA CITY
ISSUED AT

SIGNATURE (Sign inside the box)

2016-01-21

02 / 11 / 2016

ISSUED ON (mm/dd/yyyy)

DATE ACCOMPLISHED

STA ANA, BEVERLY MACARAIG - T15097794

RIGHT THUMBMARK

CS FORM 212 (Revised 2005), Page 3 of 3