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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 MONTAÑEZ
FIRST NAME JERYL
MIDDLE NAME ORTIZ 3. NAME EXTENSION (e.g. Jr., Sr.) N/A
4. DATE OF BIRTH (mm/dd/yyyy) 07/241986 16. RESIDENTIAL ADDRESS
0090, P. Bidlisiw, Lower Pulacan, Labangan, Zamboanga del Sur5. PLACE OF BIRTH LANTIAN, LABANGAN, ZDS
6. SEX
7. CIVIL STATUS ZIP CODE 7017
17. TELEPHONE NO. N/A
18. PERMANENT ADDRESS
0348, V. Sagun Street, San Francisco District, Pagadian City.8. CITIZENSHIP FILIPINO
9. HEIGHT (m) 1.5
10. WEIGHT (kg) 45 ZIP CODE 7016
11. BLOOD TYPE "A" 19. TELEPHONE NO. N/A
GSIS ID NO. 2003916922 20. E-MAIL ADDRESS (if any)
13. PAG-IBIG ID NO. 21. CELLPHONE NO. (if any) 09099771701
14. PHILHEALTH NO. 140251348207 22. AGENCY EMPLOYEE NO. 5060034
15. SSS NO. 1008196355 23. TIN 284351783
II. FAMILY BACKGROUND
24. SPOUSE'S SURNAME N/A 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
FIRST NAME N/A
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
(Continue on separate sheet if necessary)
26. FATHER'S SURNAME MONTAÑEZ
FIRST NAME OSCAR
MIDDLE NAME OSERA
27. MOTHER'S MAIDEN NAME
SURNAME ORTIZ
FIRST NAME LEAH
MIDDLE NAME ABELLO
N/A
N/ALEVEL
From To
ELEMENTARY LANTIAN ELEMENTARY SCHOOL 1999 1993 1999 VALEDICTORIAN
SECONDARY 2003 1999 2003
COLLEGESOUTHERN MINDANAO COLLEGES 2007 2003 2007 CUM LAUDE
GRADUATE STUDIES SOUTHERN MINDANAO COLLEGES 2010 2008 2010
SOUTHERN MINDANAO COLLEGES 9 units 2010 PRESENT
(Continue on separate sheet if necessary)
Page 1 of 4
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 SCHOLARSHIP/
ACADEMIC HONORS RECEIVED
ZAMBOANGA DEL SUR SCHOOL OF ARTS AND TRADES
3RD HONORABLE MENTION
VOCATIONAL / TRADE COURSE
BACHELOR OF SECONDARY EDUCATION
MASTER OF ARTS IN EDUCATION
DOCTOR OF EDUCATION
Annulled Others, specify ___________
Single Married
Widowed Separated
Male Fem ale
29.RATING PLACE OF EXAMINATION / CONFERMENT
LICENSE (if applicable)
NUMBER
LICENSURE EXAMINATION FOR TEACHERS 79.20% 08/26/2007 OZAMIZ CITY 0955801
CIVIL SERVICE P.D. 907 10090406
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
From To
09/10/2009 PRESENT TEACHER-I DepED, TAWAGAN SUR NHS 14,198 PERMANENT YES
06/01/2009 09/09/2009 DepED, TAWAGAN SUR NHS TEACHER AIDE YES
02/06/2009 04/03/2009 TEACHER AIDE YES
01/05/2009 02/05/2009 14, 026 SUBSTITUTE YES
06/10/2008 01/04/2009 TEACHER AIDE YES
01/03/2008 03/31/2008 12, 933 SUBSTITUTE YES
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(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 2 of 4
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE
DATE OF EXAMINATION / CONFERMENT DATE OF
RELEASE
12-20-2007
03-20-2007
INCLUSIVE DATES (mm/dd/yyyy) 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)
GRADE 11
DepED, ZAMBOANGA DEL SUR SCHOOL OF ARTS AND TRADES
DepED, ZAMBOANGA DEL SUR SCHOOL OF ARTS AND TRADES
GRADE 10
DepED, ZAMBOANGA DEL SUR SCHOOL OF ARTS AND TRADES
DepED, ZAMBOANGA DEL SUR SCHOOL OF ARTS AND TRADES
GRADE 10
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
31.POSITION / NATURE OF WORK
From To
N /A N/A N/A N/A N/A
/ / / /
/ / / /
/ / / /
/ / / /
(Continue on separate sheet if necessary)
VII. TRAINING PROGRAMS (Start from the most recent training.)
32.
From To
06/04/2010 06/05/2010 16TSNHS, PAGADIAN CITY
04/26/2010 04/30/2010 40
1ST REGIONAL ENGLISH FESTIVAL FOR SECONDARY SCHOOLS 11/04/2009 11/06/2009 24 DepED, REGION IX
DIVISION CLUSTER IN-SERVICE TRAINING FOR TEACHERS 10/28/2009 10/30/2009 24 DepED, PAGADIAN CITY
10/19/2009 10/21/2009 24 DepED, REGION IX
6/20/2009 and 06/27/2009 16 TAWAGAN SUR NHS
10/29/2009 10/20/2009 18
WORKSHOP ON THE VALIDATION OF SBM ASSESSMENT TOOLS FOR LEVEL 1, 2 AND 3 05/16/2008 05/16/2008 8 DepED, PAGADIAN CITY
COMMUNITY-BASED MINITORING SYSTEM 10/03/2007 10/03/2007 8 MUNICIPALITY OF LABANGAN
2002 BASIC EDUCATION CURRICULUM 01/26/2007 01/27/2007 16 SOUTHERN MINDANAO COLLEGES
BASIC TRAINING COURSE FOR TROOP LEADERS 01/18/2007 01/20/2007 38
5TH MINDANAO RIZAL YOUTH LEADERSHIP INSTITUTE 11/03/2005 11/06/2005 45 ORDER OF THE KNIGHTS OF RIZAL
05/19/2003 05/21/2003 24 MUNICIPALITY OF LABANGAN
BASIC LEADERSHIP TRAINING 02/23/2002 03/24/2002 16
/ / / /
(Continue on separate sheet if necessary)
VIII. OTHER INFORMATION
33. SPECIAL SKILLS / HOBBIES: 34. 35.
COMPUTER ENCODING ORDER OF THE KNIGHTS OF RIZAL
SURFING THE NET
HOSTING YOUTH EXCELLENCE AWARDEE
DANCING
WATCHING MOVIES
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
NAME & ADDRESS OF ORGANIZATION (Write in full)
INCLUSIVE DATES
(mm/dd/yyyy) NUMBER OF HOURS
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES (Write in full)
INCLUSIVE DATES OF ATTENDANCE
(mm/dd/yyyy) NUMBER OF HOURS
CONDUCTED/ SPONSORED BY (Write in full)
TWO DAY HANDS-ON TRAINING ON BASIC COMPUTER OPERATION PROGRAM ACTIVITIES
TRAINING ON ENGLISH CONTENT COURSES FOR SECONDARY PUBLIC SCHOOL TEACHERS IN ENGLISH
DepED, REGION IX in cooperation with UNIVERSIDAD DE ZAMBOANGA
TRAINING-WORKSHOP FOR UNTRAINED SCHOOL PAPER ADVISERS AND POTENTIAL CAMPUS JOURNALISTS
SCHOOL-BASED ROLL OUT OF SBM ADVOCACY MATERIALS AND TRAINING OF TEACHERS FOR THE ASSESSMENT OF SBM PRACTICES
SCHOOL-BASED INSET ON TEACHING STRATEGY, METHODOLOGY AND PEDAGOGY IN CONTEXTUALIZING TECH-VOC SUBJECTS IN ENGLISH, SCIENCE AND MATH
ZAMBOANGA DEL SUR SCHOOL OF ARTS AND TRADES
BSP ZAMBO.SUR- SIBUGAY- PAGADIAN CITY COUNCIL
INTEGRATED SANGGUNIANG KABATAAN ORGANIZATIONAL LEADERSHIP BASIC ORIENTATION SEMINAR
THE PHILIPPINE NATIONAL RED CROSS
NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write
in full)
CHAMPION- 12TH PROVINCIAL STATISTICS QUIZ PROVINCIAL ELIMINATIONS
CHAMPION- 4-H CLUB EXTEMPORANEOUS SPEECH CONTEST
4-H CLUB, DEPARTMENT OF AGRICULTURE
RESERVE OFFICERS TRSINING CORPS
NATIONAL ORGANIZATION OF PROFESSIONAL TEACHERS, INC.
36. Are you related by consanguinity or affinity to any of the following :
a.
b.
37 a. Have you ever been formally charged?
b. Have you ever been guilty of any administrative offense?
38.
39.
40. Have you ever been a candidate in a national or local election (except Barangay election)?
41.
a. Are you a member of any indigenous group?If YES, please specify: ____________________
b. Are you differently abled?If YES, please specify: ____________________
c. Are you a solo parent?If YES, please specify: ____________________
42.
NAME ADDRESS TEL. NO.
GLORIA T. LONGINOS TSNHS, PRINCIPAL-II 9184525974
AURORA M. IBRAHIM SMC, ASST. DEAN OF GRADUATE SCHOOL 215-2589
JUDITH V. ROMAGUERA DepED R9 9297095782
43.
PHOTO
01084804
COMMUNITY TAX CERTIFICATE NO.
TAWAGAN SUR, PAGADIAN CITYISSUED AT
01/12/2011 02/02/2011ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK
CS FORM 212 (Revised 2005), Page 4 of 4
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?
If YES, give details: _____________________________________ _____________________________________ _____________________________________
Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? If YES, give details:
_____________________________________ _____________________________________ _____________________________________
If YES, give details: ________________________________ ________________________________
If YES, give details: ________________________________ ________________________________
Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? If YES, give details:
________________________________ ________________________________
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?
If YES, give details: ________________________________ ________________________________
If YES, give details: ________________________________ ________________________________
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:
REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)
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.
SIGNATURE (Sign inside the box)
ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)
Computer generated or xerox copy of picture
is not acceptable
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO