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CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15346270


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 CUSAY
FIRST NAME QUEENIE
MIDDLE NAME VIGO 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS MILAN, JAMINDAN, CAPIZ


4. DATE OF BIRTH (mm/dd/yyyy) 08 / 09 / 1994
5. PLACE OF BIRTH JAMINDA,CAPIZ
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 5808
Married Separated
17. TELEPHONE NO. 09075403500
Annuled Others, specify
_________ 18. PERMANENT ADDRESS MILAN, JAMINDAN, CAPIZ

8. CITIZENDSHIP FILIPINO
9. HEIGHT (m) 4'11
10. WEIGHT (kg) 147 ZIP CODE 5808
11. BLOOD TYPE O+ 19. TELEPHONE NO. 09075403500
12. GSIS ID NO. 20. EMAIL ADDRESS (if any) cusayqueen_09@mail.com
13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any)

14. PHILHEALTH NO. 110253880279 22. AGENCY EMPLOYEE NO.

15. SSS NO. 23. TIN

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUS. NAME

BUSINESS ADDRESS

TELEPHONE NO.

(Continue on separate sheet if necessary)

26. FATHER'S SURNAME CUSAY

FIRST NAME QUEENIE

MIDDLE NAME VISTA

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME VIGO

FIRST NAME LETICIA

MIDDLE NAME VALLITE

III. EDUCATIONAL BACKGROUND


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

MILAN ELEMENTARY 06-03- 03-30-


ELEMENTARY 2007 NONE
SCHOOL 2001 2007

JAMINDAN NATIONAL HIGH 06-07- 03-27-


SECONDARY 2011 NONE
SCHOOL 2007 2011
MAYHEKS CULINARY ARTS
VOCATIONAL/ TRADE 2018-22- 2018-15-
AND RESTAURANT COOKERY NC II 2018 TESDA
COURSE 10 12
SERVICES INSTITUTE INC.
BACHELOR OF
FILAMER CHRISTIAN 2011-06-
COLLEGE SECONDARY 2013- NONE
UNIVERSITY 06
EDUCATION
BACHELOR OF
CAPIZ STATE UNIVERSITY- 2014-11- 2017-03- GUGMA NI CASTRO-
SECONDARY 2017
BURIAS CAMPUS 05 27 RECIPIENT
EDUCATION

CUSAY, QUEENIE VIGO - T15346270 CS FORM 212 (Revised 2005), Page 1 of 3


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

GRADUATE STUDIES

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

CES ELIGIBLE (CAREER EXECUTIVE SERVICE


81.40 09 / 24 / 2017 ILOILO NATIONAL HIGH SCHOOL 1611918 01/16/2018
ELIGIBILITY)

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")

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

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

COOKERY NC II 10 / 22 / 2018 12 / 15 / 2018

COEUS REVIEW AND


SEMINAR-WORKSHOP IN DESIGNING AND DEVELOPING
04 / 22 / 2018 04 / 23 / 2018 10 TRAINING SPECIALIST
EDUCATIONAL RESEARCH
INCORPORATED

VIII. OTHER INFORMATION


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

SINGING COOKING GARDENING


ORGANIZING THINGS READING BOOKS NONE NONE
(NOVELS, MAGAZINE) WATCHING MOVIES

CUSAY, QUEENIE VIGO - T15346270 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.

CHERRY G. VIGO MILAN, JAMINDAN, CAPIZ 09388848129

JOSEPHINE V. VIGO LINAMBASAN, JAMINDAN, CAPIZ 09095280805

JOGENE VALGUNA POBLACION, JAMINDAN, CAPIZ 09093813989

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

08237688

COMMUNITY TAX CERTIFICATE NO.

JAMINDAN

ISSUED AT SIGNATURE (Sign inside the box)

2019-01-28 01 / 29 / 2019

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

CUSAY, QUEENIE VIGO - T15346270 CS FORM 212 (Revised 2005), Page 3 of 3