Professional Documents
Culture Documents
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME PATOSA
NAME EXTENSION (JR., SR
FIRST NAME SHIRLYN JOY
OCCUPATION OFW
TELEPHONE NO.
SURNAME CAPINPIN
SECONDARY /
VOCATIONAL PANIKIAN NATIONAL HIGH SCHOOL 6/5/2000 3/30/2004
TRADE
COURSE BACHELOR OF TECHNICIAN TEACHER
COLLEGE SURIGAO DEL SUR STATE UNIVERSITY
EDUCATION-HELE
6/5/2004 3/30/2008
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person
Dual Citizenship
by naturalization
Street
PAG-ANTAYAN
Barangay
SURIGAO DEL SUR
Province
8317
Street
PAG-ANTAYAN
Barangay
SURIGAO DEL SUR
Province
09127082129
11/28/2013
(Continue on separate sheet if necessary)
SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED
2000
2004
2008
June 8, 2017
Date of
Validity
12/23/2018
GOV'T
SERVICE
(Y/
N)
arate sheet if necessary)
BAKING
CAKE DECORATING
TABLE SKIRTING
SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S
VOLUNTEER TEACHER
CONDUCTED/ SPONSORED BY
(Write in full)
eparate sheet if necessary)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
6/8/2017
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
a. Have you ever been found guilty of any administrative offense? YES NO
35.
b. Have you resigned from the government service during the three (3)-month period before the last
election to promote/actively campaign for a national or local candidate? YES If YES, give details:
NO
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):
40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons (RA YES NO
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?
If YES, please specify ID No:
REMESON TRUGILLO, PRINCIPAL I PANIKAIN, CARRASCAL, SDS With full and handwritten
name tag and signature over
printed name
DORIE T. GEDUCOS TANDAG CITY
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:
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.