CS FORM 212 (Revised 2005)
PERSONAL DATA SHEET
Print legibly. Mark the appropriate boxes with”” and use separate sheet if necessary.
1. CS ID No.
(to be filled up by CSC)
I. PERSONAL INFORMATION
2.
SURNAME
PRAC
FIRST NAME
MICHAEL
MIDDLE NAME
DEASIS
3. NA
EXTENSION (e.g. Jr., Sr.)
4.
DATE OF BIRTH (mm/dd/yyyy-. RESIDENTIAL ADDRESS
18 A. REGIDOR ST. LUCBAN, QUEZON
5.
PLACE OF BIRTH
LUCBAN, QUEZON
6.
SEX
Male
Female
7.
CIVIL STATUS
Single
Widowed
Married
Separated
Annulled
Others, specify____________
ZIP CODE
4328
17. TELEPHONE NO-
18. PERMANENT ADDRESS
18 A. REGIDOR ST. LUCBAN, QUEZON
8.
CITIZENSHIP
FILIPINO
9.
HEIGHT (m)
162.56m
10.
WEIGHT (kg)
65kg
ZIP CODE
4328
11.
BLOOD TYPE
AB
19. TELEPHONE NO-.
GSIS ID NO-. E-MAIL ADD
ESS (if any)-13.
PAG-IBIG ID NO-. CELLPHONE NO. (if any-.
PHILHEALTH NO-. AGENCY EMPLOYEE NO-.
SSS NO.
NONE
23. TIN-
II. FAMILY BACKGROUND
24.
SPOUSE'S SURNAME
RADA
25. NAME OF CHILD (Write full name and list all)
DATE OF BIRTH
FIRST NAME
AMELIA
MIKAELA ANGELA R. PRAC
02 / 15 /2005
MIDDLE NAME
RACELIS
MICHAEL ANGELO R. PRAC
03 / 25 /2007
OCCUPATION
HOUSEKEEPER
MIKHAIL R. PRAC
04 / 12 /2009
EMPLOYER/BUS. NAME
N/A
/ /
BUSINESS ADDRESS
N/A
/ /
TELEPHONE NO.
N/A
/ /
(Continue on separate sheet if necessary)
/ /
26.
FATHER'S SURNAME
PRAC
/ /
FIRST NAME
SERGIO
/ /
MIDDLE NAME
ALMONTE
/ /
27.
MOTHER'S MAIDEN NAME
/ /
SURNAME
DEASIS
/ /
FIRST NAME
SIMEONA
/ /
MIDDLE NAME
SALVOSA
(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 graduated)
HIGHEST GRADE/ LEVEL/ UNITS EARNED (if not graduated)
INCLUSIVE DATES OF ATTENDANCE
SCHOLARSHIP/ ACADEMIC HONORS RECEIVED
From
To
ELEMENTARY
PAARALANG BAYAN NG LUCBAN-1
ELEMENTARY
1989
GRADUATED-
NONE
SECONDARY
SOUTHERN LUZON POLYTECHNIC COLLEGE
SECONDARY
1993
GRADUATED-
NONE
VOCATIONAL
SOUTHERN LUZON POLYTECHNIC COLLEGE
3YR. ELECTRICAL TECHNOLOGY
1996
GRADUATED-
NONE
COLLEGE
SOUTHERN LUZON POLYTECHNIC COLLEGE
BACHELOR OF SECONDARY EDUCATION
1998
51 UNITS-
NONE
MANUEL S. ENVERGA UNIVERSITY FOUNDATION LUCENA CITY
BACHELOR OF SECONDARY EDUCATION
2004
GRADUATED-
NONE
GRADUATE STUDIES
NONE
N/A
N/A
N/A
N/A
N/A
N/A
(Continue on separate sheet if necessary)
Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
29.
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE
RATING
DATE OF EXAMINATION / CONFERMENT
PLACE OF EXAMINATION / CONFERMENT
LICENSE (if applicable)
NUMBER
DATE OF RELEASE
LICENSURE EXAMINATION FOR TEACHERS
81
AUG. 29, 2004
MSEUF LUCENA CITY-
(Continue on separate sheet if necessary)
V. WORK EXPERIENCE (Include private employment. Start from your current work)
30.
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)
From
To
-
PRESENT
SECONDARY TEACHER I
DEPT. OF EDUCATION LUIS PALAD NATIONAL HIGH SCHOOL
P-
PERMANENT
YES-
SECONDARY TEACHER I
DEPT. OF EDUCATION LUIS PALAD NATIONAL HIGH SCHOOL
P-
PERMANENT
YES-
SECONDARY TEACHER I
DEPT. OF EDUCATION LUTUCAN NATIONAL HIGH SCHOOL
P-
PERMANENT
YES
06- -
SECONDARY TEACHER I
DEPT. EDUCATION LUTUCAN NATIONAL HIGH SCHOOL ANNEX
P7 000
LOCALLY FUNDED
YES
(Continue on separate sheet if necessary)
Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
31. NAME & ADDRESS OF ORGANIZATION (Write in full)
INCLUSIVE DATES (mm/dd/yyyy)
NUMBER OF HOURS
POSITION / NATURE OF WORK
From
To
SAMAHAN NG GURO AT KAWANI-LUIS PALAD NATIONAL HIGH SCHOOL
08- -2013
PRESENT
MEMBER
(Continue on separate sheet if necessary)
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)
NUMBER OF HOURS
CONDUCTED/ SPONSORED BY
(Write in full)
From
To
SEMINAR WORKSHOP ON INTERACTIVE, INTEGRATIVE AND COLLABORATIVE TEACHING STRATEGIES AND OUTCOMES/COMPETENCY- BASED ASSESSMENT FOR HIGHER- ORDER THINKING SKILLS-
PROFESSIONAL REGULATION COMMISSION
ENHANCEMENT OF TEACHER’S COMPETENCIES ON LEARNING RESOURCE DEVELOPMENT THROUGH LOCALIZATION AND CONTEXTUALIZATION OF IMS-
CITY SCHOOLS DIVISION OF TAYABAS
DIVISION TRAINING- WORKSHOP ON CLASSROOM BASED ASSESSMENT FOR TEACHERS UNDER K-12 CURRICULUM-
CITY SCHOOLS DIVISION OF TAYABAS
INSET-CLUSTER-BASED-
CITY SCHOOLS DIVISION OF TAYABAS
CHILD PROTECTION POLICY-
CITY GOVERNMENT OF TAYABAS
INSET CLUSTER-BASED-
CITY SCHOOLS DIVISION OF TAYABAS
INTENSIFIED GUIDANCE AND COUNSELING PROGRAM:A PROPELLER FOR A BETTER STUDENT’S ADVOCACY-
DEPARTMENT OF EDUCATION REGION IV-A
SCHOOL LEVEL IN-SERVICE TRAINING-
LUTUCAN NATIONAL HIGH SCHOOL
REGIONAL MASS TRAINING FOR SECONDARY TEACHERS ON 2010 SECONDARY EDUCATION CURRICULUM-
DEPARTMENT OF EDUCATION REGION IV-A
DIVISION SEMINAR WORKSHOP IN VALUES EDUCATION-
DIVISION OF QUEZON
DIFFERENTIATING AND ADVANCING INSTRUCTION IN SCIENCE BY USING THE PROMETHEAN BOARD-
NORTHWESTERN HIGH SCHOOL USA AND LUTUCAN NATIONAL HIGH SCHOOL
SBM TRAINING WORKSHOP FOR TEACHERS-
DIVISION OF QUEZON
REGIONAL TRAINING FOR SECONDARY SCHOOL NON-MAJOR TEACHERS IN SCIENCE AND MATH-
LUTUCAN NATIONAL HIGH SCHOOL
CLUSTER-III-A AND B SCHOOL-BASED MANAGEMENT WORKSHOP-
DIVISION OF QUEZON CLUSTER III-A
ENSCIMA TRAINING WORKSHOP-
GOVERNMENT OF SPAIN AND THEPHILIPPINES EDPITAF
VIII. OTHER INFORMATION
33.
SPECIAL SKILLS / HOBBIES:
34.
NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)
35.
MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)
DRAWING/SKETCHING
OPISYAL NG BASEBALL PALARONG PAMPAARALAN 2016
SAMAHAN NG MGAGURO AT KAWANI
MONOBLOC/T-SHIRT PRINTING
STAGE DECORATOR MISS PALADIAN PERSONALITY 2015
STYRO-CUTTING
OPISYAL NG BASEBALL PALARONG PAMPAARALAN 2014
BUILDING/ELECTRICAL WIRING
ELECTRIC MOTOR CONTROL
(Continue on separate sheet if necessary)
CS FORM 212 (Revised 2005), Page 3 of 4
36.
a.
b.
Are you related by consanguinity or affinity to any of the following :
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?
Yes
No
If yes, give details:
_____________________________________
_____________________________________
Within the fourth degree (for Local Government Employ
es): appointing authority or
recommending authority where you will be appointed?
Yes
No
If yes, give details:
_____________________________________
_____________________________________
37
a. Have you ever been formally charged?
Yes
No
If yes, give details:
_____________________________________
_____________________________________
b.
Have you ever been guilty of any administra
ive offense?
Yes
No
If yes, give details:
_____________________________________
_____________________________________
38.
Have y
u ever been convicted of any crime or violation of any law, decree, or
inance or regulation by any court or tribun
l?
Yes
No
If yes, give details:
_____________________________________
_____________________________________
39.
Have you ever been separated from the service in any of the following modes: resignatio
, retirement, dropped from the rolls, dismi
sal, termination, end of term, finished contract, AWOL or phased out, in the public or private sector?
Yes
No
If yes, give details:
_____________________________________
40.
Have you ever been a can
idate in a national or local election (exce
t Barangay election)?
Yes
No
If yes, give details:
_____________________________________
_____________________________________
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:
_____________________________________
b.
Are you di
ferently abled?
Yes
No
If yes, please specify:
_____________________________________
c.
Are you a solo parent?
Yes
No
If yes, please specify:
_____________________________________
42.
REFERENCES (Persons not related by consanguinity or affinity to applicant / appointee)
NAME
ADDRESS
TEL. NO.
PHOTO
MARICEL SOTTO
SARIAYA QUEZON-
MARITESS CAGUJAS
LOPEZ, QUEZON-
43.
I hereby declare under oath that this Personal Data Sheet has been accomplished by me, and is true and 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
-
COMMUNITY TAX CERTIFICATE NO.
TAYABAS QUEZON
ISSUED AT.
-
ISSUED ON
CS FORM 212 (Revised 2005) Page 4 of 4)
