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

12. je_ryl_05@yahoo.com.ph

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