CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15345105

1. CS ID
Print legibly. Mark appropriate boxes with " " and use separate sheet if necessary. No. (to be filled up by CSC)

I. PERSONAL INFORMATION
2. SURNAME CASIA
FIRST NAME ALBERT
MIDDLE NAME ROMERO 3. NAME EXTENSION (e.g. Jr., Sr.) JR.
16. RESIDENTIAL ADDRESS Purok 3, San Vicente II, TAGBINA, SURIGAO DEL
4. DATE OF BIRTH (mm/dd/yyyy) 08 / 11 / 1997
SUR
San Vicente II, Tagbina,
5. PLACE OF BIRTH
Surigao del Sur
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 8308
Married Separated
17. TELEPHONE NO. N/A
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Purok 3, San Vicente II, TAGBINA, SURIGAO DEL
SUR
8. CITIZENDSHIP Filipino
9. HEIGHT (m) 1.67
10. WEIGHT (kg) 75 ZIP CODE 8308
11. BLOOD TYPE O+ 19. TELEPHONE NO. N/A
12. GSIS ID NO. N/A 20. EMAIL ADDRESS (if any) [email protected]
13. PAGIBIG ID NO. N/A 21. CELLPHONE NO. (if any) 09121639448
14. PHILHEALTH NO. N/A 22. AGENCY EMPLOYEE NO. N/A
15. SSS NO. N/A 23. TIN 736-221-993-000

II. FAMILY BACKGROUND

24. SPOUSE'S SURNAME 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME N/A 01 / 01 / 1970

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME Casia

FIRST NAME Albert, Sr.

MIDDLE NAME Soriano

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Romero

FIRST NAME Divina

MIDDLE NAME Cardino

III. EDUCATIONAL BACKGROUND

HIGHEST
GRADE/ INCLUSIVE DATES OF
YEAR ATTENDANCE
LEVEL NAME OF SCHOOL DEGREE COURSE LEVEL/ UNITS SCHOLARSHIP/ ACADEMIC
GRADUATED
(Write in full) (Write in full) EARNED HONORS RECEIVED
(if graduated)
(if not
graduated) From To

San Vicente II Elementary 2004-06- 2010-03-

ELEMENTARY 2010 6 N/A
School 07 26

San Vicente II National High 2010-06- 2014-03-

SECONDARY 2014 N/A
School 07 28

VOCATIONAL/ TRADE
N/A N/A N/A
COURSE

Expanded Students’
Surigao del Sur State
Bachelor of 2014-06- 2018-03- Grants-in-Aid Program for
COLLEGE University - Main Campus 2018
Secondary Education 09 27 Poverty Alleviation
Tandag City
(ESGP-PA)

CASIA, ALBERT ROMERO - T15345105 CS FORM 212 (Revised 2005), Page 1 of 3

III. EDUCATIONAL BACKGROUND
HIGHEST
GRADE/ INCLUSIVE DATES OF
YEAR ATTENDANCE
LEVEL NAME OF SCHOOL DEGREE COURSE LEVEL/ UNITS SCHOLARSHIP/ ACADEMIC
GRADUATED
(Write in full) (Write in full) EARNED HONORS RECEIVED
(if graduated)
(if not
graduated) From To

GRADUATE STUDIES N/A N/A N/A

IV. CIVIL SERVICE ELIGIBILITY

29. LICENSE (if applicable)
DATE OF
CAREER SERVICE/ RA 1080 (BOARD/ BAR)
RATING EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
UNDER SPECIAL LAWS/ CES/ CSEE DATE OF
CONFERMENT NUMBER
RELEASE

LET (LICENSURE EXAMINATION FOR

81.80% 09 / 30 / 2018 Cagayan De Oro City 1706137 01/07/2019
TEACHER)

V. WORK EXPERIENCE
30. INCLUSIVE DATES SALARY
(mm/dd/yyyy) GRADE &
DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF GOV'T SERVICE
POSITION TITLE (Write in full) STEP
COMPANY (Write in full) SALARY APPOINTMENT (Yes / No)
INCREMENT
From To
(Format "00-0")

San Vicente II National High

06/07/2018 04/08/2019 Volunteer Teacher N/A 0-0 Volunteer Yes
School

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

31. INCLUSIVE DATES
NAME & ADDRESS OF ORGANIZATION (mm/dd/yyyy) NUMBER OF
POSITION / NATURE OF WORK
(Write in full) HOURS
From To

N/A N/A

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

32. INCLUSIVE DATES OF
ATTENDANCE
TITLE OF SEMINAR/CONFERENCE/WORKSHOP/SHORT COURSES NUMBER OF CONDUCTED/ SPONSORED BY
(mm/dd/yyyy)
(Write in full) HOURS (Write in full)
From To

TECHNICAL EDUCATION AND

2D DIGITAL ANIMATION AND VISUAL DESIGNS NC III 01 / 03 / 2019 01 / 27 / 2019 80 SKILLS DEVELOPMENT
AUTHORITY

VIII. OTHER INFORMATION

33. 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION: 35. MEMBERSHIP IN ASSOCIATION / ORGANIZATION
SPECIAL SKILLS / HOBBIES:
(Write in full) (Write in full)

Computer Literate N/A N/A

CASIA, ALBERT ROMERO - T15345105 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): YES NO

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 If YES, give details:
appointed? _____________________________________
_____________________________________
_____________________________________

b. Within the fourth degree (for Local Government Employees): YES NO

appointing authority or recommending authority where you will be appointed?
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 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 YES NO
regulation by any court or tribunal?
If YES, give details:
_____________________________________
_____________________________________

39. Have you ever been separated from the service in any of the following modes: resignation, YES NO
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:
_____________________________________
_____________________________________

40. Have you ever been a candidate in a national or local election (except 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 differently abled? YES NO
If YES, please specify:_______________________
c. Are you a solo parent? YES NO
If YES, please specify:_______________________

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

NAME ADDRESS TEL. NO.

Merjorie G. Dalagan San Vicente II, Tagbina, Surigao del Sur NONE

Charlie C. Romero Rosario, Tandag City, Surigao del Sur NONE

Merlinda M. Miraflor Maglatab, Tagbina, Surigao del Sur NONE

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.
X
I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that
this information shall remain confidential. PHOTO

17765417

COMMUNITY TAX CERTIFICATE NO.

San Vicente II, Tagbina, Surigao del Sur

ISSUED AT SIGNATURE (Sign inside the box)

2019-01-07 01 / 28 / 2019

ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED RIGHT THUMBMARK

CASIA, ALBERT ROMERO - T15345105 CS FORM 212 (Revised 2005), Page 3 of 3