Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
Lingayen

Mon 7/12/2021 2:11 AM

CHECKLIST
(Processing of Appointment)

Name of Appointee: RIZALYN C. CATALMA Item No. TCH1-78486-1998

ü Teaching
Non-Teaching ü Elementary Junior High Senior High
Track
Supporting Documents:
SUBMIT IN 3 LONG BROWN FOLDERS (w/ a COPY of each document arranged in below order)

ü CS Form 4 (Certification of Assumption to Duty) St. Address Kawayan St. Sablig

CS Form 33 (Appointment Form) Town, Prov. Anda, Pangasinan
ü Certification of Availability of Funds School Bolinao IS
ü DBM-CSC Form 1 (PDF - Position Description Form) Position SUBSTITUTE TEACHER Bolinao

Duly Approved ERF (in case of salary adjustment) Status

Special Order of Separation ( __Retired __Transfer __Resigned Regular ü 1st Tranche

__Approved GSIS voucher if retired) SG / Step

Annual Monthly
Previous Appointment (for transfer) Appointment Type
ü CS Form 212 (PDS - Personal Data Sheet)
ü CS Form 32 (Oath of Office)
ü Updated Service Record / Certificate of Employment VICE GRACE M. BARCELONA
ü Official Transcript of Records (Certified True copy) Vice Reason MATERNITY LEAVE
NC __________ TMC __________ (for SHS TVL only) Date of Signin 11/12/2020
ü PRC License _____ Cert. of Registration _____ PRC Rating
ü CS Form 211 (Medical Certificate) Education
ü Statement of Assets and Liabilities (SALN) Experience
ü Clearances ___Brgy. ___Police ___NBI (for original appt. only) Training
Copy of Pub. / Date of Publicatio Eligibility
ü Approved Form 6 (for Substitute) BDAY November 30, 1995
Contact Numbers: TIN 701-879-416
Appointee: 0948 373 4002 Orig. Appt.
School Head: 0921 767 4357 MA. CECILIA T. BALGUA

RECOMMENDATION:
OK as to Item No. and Supporting Documents
Please comply w/ the lacking documents:

DANIEL C. VENTURA Date:

In-Charge
Processing Appointment
Noted:
VANNITY KAYE D. SISON
 Administrative Officer IV

download forms @ http://tiny.cc/sdo1-apptFORMS

 APPOINTMENT PROCESSING FORM

FULL NAME RIZALYN C. CATALMA F MS.

Item No. TCH1-78486-1998 TCH1
Level ELEMENTARY TVL TEACHER I TVL
St. Address KAWAYAN ST. SABLIG
Town, Province ANDA, PANGASINAN
School Assignment Bolinao IS Bolinao
Position TEACHER I Teaching T-I
Status SUBSTITUTE font: ARIAL 36 x3 folders
SG / Step 19 1
Appt Type
VICE GRACE M. BARCEL0NA
Vice Reason MATERNITY LEAVE
Date of Publication
Education BEED BEE or Bachelors's de
Experience None Required
Training NONE REQUIRED None Required
Eligibility LET LET, PBET, RA 1080 T
Birthday NOVEMBER 30, 1995
TIN 701-879-416
Original Appt
Contact No. 0948 373 4002
School Head/Principal MA. CECILIA T. BALGUA MA. CECILIA T. BALGUA
Signatory SHEILA MARIE A. PRIMICIAS, CESO VI #N/A

BOLINAO I RUTH C. CAALAMAN

BOLINAO II JOEY C. CASERIAL

#N/A

TEMPORAR
PERMANENT CONTRACTUAL
Y
SUBSTITUTE PROVISIONA
L

ORIGINAL RE-APPT. TRANSFER

RE-EMP.
PROMOTION RECLASS
BEE or Bachelors's degree plus 18 Educ. Prof. units
None Required
None Required
LET, PBET, RA 1080 Teachers
CS Form No. 4
Series of 2017
Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
Alvear St. Lingayen, Pangasinan
Tel. No./Fax No. (075) 522-2202(OSDS);(075) 632-8385(ASDS)
E-mail: pangasinan1@deped.gov.ph ; officeofthesdspangasinani@gmail.com Position Title

District / Municipality
CERTIFICATION OF ASSUMPTION TO DUTY Effective Date

This is to certify that RIZALYN C. CATALMA has assumed

the duties and responsibilities as TEACHER I of Bolinao Integrated School, Issued Month
Bolinao, Pangasinan effective __________________________.

This certification is issued in connection with the issuance of the appointment

of Mr./Ms. RIZALYN C. CATALMA as TEACHER I.

Done this ______ day of _______________ in Lingayen, Pangasinan.

MA. CECILIA T. BALGUA

SCHOOL HEAD

Date:

ATTESTED BY:

NELIA C. SANTOS
Administrative Officer IV - Personnel

201 file
Admin
COA For submission to CSCFO
CSC within 30 days from the
date of assumption of the
appointee
 auto
MA. CECILIA T. BALGUA
SCHOOL HEAD

NELIA C. SANTOS SHEILA MARIE A. PRIMICIAS, CESO VI

Administrative Officer IV - Personnel Assistant Schools Division Superintendent
OIC - Office of the Schools Division Superintendent
 Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
Lingayen

CERTIFICATION

The Director
Civil Service Commission
San Fernando City, La Union

SIR / MADAM :

In connection with the proposed appointment of RIZALYN C. CATALMA, T-I

of DepED, Schools Division Office I Pangasinan, Lingayen, Pangasinan a P 119,268.00
per annum effective UPON APPROVAL in this Office, I hereby certify:

a.       That the funds the

a.     That for funds
the position
for the are available:
position are available:
b.      That position
b.     Thathas been classified
position by WAPCO
has been classified to Grade
by WAPCO to 13 Step11
Grade 1. Step 1
(P 23,778 ) to (P 23,778 ) and that the appointee will be
assigned the duties attached to the position:
c. That the provisions of law and rules on promotions, senority and nepotism
have been observed:
d. That there is no pending administrative or criminal case filed against the
proposed appointee:
e. That the provision of CSC Memorandum Circular No. 6, Series of 1967
have been observed.

Very truly yours,

SHEILA MARIE A. PRIMICIAS, CESO VI

Assistant Schools Division Superintendent
Officer-In-Charge
Office of the Schools Division Superintendent

Date

1. If the position had not been classified, the appointment should be sent to WAPCO. If the
position is not covered by the WAPCO plan, there is no need for this certification.
2. In case there is pending administrative or criminal case filed against the person
proposed for appointment, the particulars of the case should be stated.
 1. POSITION TITLE (as approved by authorized agency) with
Republic of the Philippines parenthetical title
POSITION DESCRIPTION FORM
DBM-CSC Form No. 1
)Revised Version No. 1 , s. 2017(
TEACHER I

2. ITEM NUMBER 3. SALARY GRADE

TCH1-61304-2015 11-1

4. FOR LOCAL GOVERNMENT POSITION, ENUMERATE GOVERNMENTAL UNIT AND CLASS

Province 1st Class 5th Class

City 2nd Class 6th Class
Municipality 3rd Class Special
4th Class

5. DEPARTMENT, CORPORATION OR AGENCY/ 6. BUREAU OR OFFICE

LOCAL GOVERNMENT

Department of Education Schools Division Office - Pangasinan I

7. DEPARTMENT / BRANCH / DIVISION 8. WORKSTATION / PLACE OF WORK

ELEMENTARY TONDOL ELEMENTARY SCHOOL

9. PRESENT APPROP ACT 10. PREVIOUS APPROP ACT 11. SALARY AUTHORIZED 12. OTHER COMPENSATION

P 23,778

13. POSITION TITLE OF IMMEDIATE SUPERVISOR 14. POSITION TITLE OF NEXT HIGHER SUPERVISOR

SCHOOL PRINCIPAL II SCHOOLS DIVISION SUPERINTENDENT

15. POSITION TITLE, AND ITEM OF THOSE DIRECTLY SUPERVISED

(if more than seven (7) list only by their item numbers and titles)
POSITION TITLE ITEM NUMBER

TEACHER I TCH1-61304-2015

16. MACHINE, EQUIPMENT, TOOLS, ETC., USED REGULARLY IN PERFORMANCE OF WORK

17. CONTACTS / CLIENTS / STAKEHOLDERS

17a. Internal Occasional Frequent 17b. External Occasional Frequent
Executive / Managerial General Public
Supervisors Other Agencies
Non-Supervisors Others (Please Specify):
Staff
18. WORKING CONDITION
Office Work Other/s (Please Specify)
Field Work

19. BRIEF DESCRIPTION OF THE GENERAL FUNCTION OF THE UNIT OR SECTION

To provide quality education.

20. BRIEF DESCRIPTION OF THE GENERAL FUNCTION OF THE POSITION (Job Summary)
1. Facilitates learning in the secondary school functional lesson plans, daily log of activities and appropriate, adequate and
updated instructional materials (print and non-print)
2. Monitor, asseses and evaluates students' progress.
3. Undertakes activities to improved performance indicators.
4. Maintains updated student school records.
5. Updates parents and students' progress regularly.
6. Supervises curricular and co-curricular projects and activities.
7. Counsels and guides students.
8. Conduct action research.
9. Maintains cleanliness, safety and unkeep the classroom.
10. Participates in staff development, activities and utilizes KSAs gained from seminars, trainings and scholarship.
11. Maintains harmonious relationship with fellow teachers and other school personnel as well as parents and
stakeholders.
12. Supports activities of governmental and non-governmental organizations.
13. Does related works.
21. QUALIFICATION STANDARDS
21a. Education 21b. Experience 21c. Training 21d. Eligibility

BACHELOR of
ELEMENTARY None Required None Required LET
EDUCATION

21e. Core Behavioral Competencies Competency Level

N/A

21f. Leadership Competencies Competency Level

N/A

22. STATEMENT OF DUTIES AND RESPONSIBILITIES (Technical Competencies) Competency Level

Percentage of Working (State the duties and responsibilities here:)
Time

n/a

23. ACKNOWLEDGMENT AND ACCEPTANCE:

I have received a copy of this position description. It has been discussed with me and I have freely chosen to comply
with the performance and behavior/conduct expectations contained herein.

RIZALYN C. CATALMA/ 02/10/21 CEZARDO C. LADIA/02/10/21

Employee's Name, Date and Signature Supervisor's Name, Date and Signature
note: Pls. Print form Back to Back
(for teaching only,change according to position)

To provide quality education.

 teaching
1. Facilitates learning in the secondary school functional lesson plans, daily log of
1. Assists in collection of
activities and appropriate, adequate and
updated instructional materials (print and non-print) 2. Prepares remittance an
2. Monitor, asseses and evaluates students' progress. 3. Prepares report of colle
3. Undertakes activities to improved performance indicators. 4. Draws cash advances
4. Maintains updated student school records. 5. Pays out cash for payr
5. Updates parents and students' progress regularly. 6. Controls payroll and pr
6. Supervises curricular and co-curricular projects and activities. 7. Verifies and pays salar
7. Counsels and guides students. 8. Posts and reviews the
8. Conduct action research. and accounts for cash
9. Maintains cleanliness, safety and unkeep the classroom. 9. Accounts for receipt cu
10. Participates in staff development, activities and utilizes KSAs gained from
10. Prepares report of disb
seminars, trainings
11. Maintains and scholarship.
harmonious relationship with fellow teachers and other school
11. Processes checks and
personnel as well as parents and stakeholders.
12. Supports activities of governmental and non-governmental organizations. 12. Prepares report of che
13. Does related works. 13. Controls and releases

Self-Management
Check the appropriate level
Professionalism and Ethics
Result Focus 5- Role Model
Teamwork 4-Consistently Demonstrate
3- Most of the time demonstrate
Service Orientation 2- Sometimes demonstrate
Innovation 1- Rarely demonstrate
Check the appropriate level
Leading
(please Peopledescription of competencies)
see attached
People Performance Management 5- Role Model
People Development 4-Consistently Demonstrate
3- Most of the time demonstrate
2- Sometimes demonstrate
(please see attached description of competencies) 1- Rarely demonstrate

teaching school head auto

Actual Classroom Teaching - 80% Supervision - 70%
Actual Classroom Teaching - 80%
Preparation of Lesson Plan - 15 % Administration - 30 %
Preparation of Lesson Plan - 15 %

Community Works - 5 % Community Works - 5 %

auto

MA. CECILIA T. BALGUA

 disbursing school head
collection of funds and deposits 1. Supervises and directs all school teaching and non-
emittance and deposit slips 2. Manages instructional system
eport of collections and deposits 3. Leads and implements educational program
4. Promotes and coordinates services for the holistic d
h advances for trainings as designated disbursing officer
personnel and pupils
ash for payrolls and vouchers 5. Directs, coordinates and manages school funds acc
ayroll and prepares vouchers for salaries and wages 6. Inspects regularly Daily Lesson Logs (DLL)
d pays salaries and wages and other disbursements 7. Prepares/consolidates reports
reviews the posting of disbursement to the cash book 8. Rates all school personnel preformance and recomm
nts for cash advance received 9. Creates committee to assess learning outcomes
or receipt custody and disbursement of funds 10. Promotes welfare of stakeholders
11. Ensures compliance to existing laws,policies and o
report of disbursements
for the school
s checks and advise of checks issued and cancelled 12. Establishes linkages with the stakeholders
report of checks issued and cancelled 13. Recognizes accomplishments of stakeholders
and releases approved checks to DepEd creditors 14. Mediates and ensures resolution of conflicts in sch
 l head guidance
ing and non-teaching personnel 1. Provides orientation to students in all year levels
2. Formulates guidance and counseling forms including individual inventory,
agreement forms
3. Administers and interprets individual and groups psychological and projective
gram
the holistic development of school tests
4. Provides effective individual and group counseling
ool funds according to prioritized needs 5. Identifies students' needs and problems
6. Makes an action research based on the results of the identified of students'
DLL)
needs and problems
7. Makes referrals to different government agencies
e and recommends promotion 8. Coordinates with the community, NGOs or Gos for program support
outcomes 9. Provides career counseling to students
9. Maintains cleanliness, safety and unkeep the classroom.
olicies and orders of fund raising projects
10. Provides scholarship programs to students
ders
eholders
nflicts in school
 auto
1. Facilitates learning in the secondary school functional lesson plans, daily log of
ntory, activities and appropriate, adequate and
updated instructional materials (print and non-print)
projective
2. Monitor, asseses and evaluates students' progress.
3. Undertakes activities to improved performance indicators.
4. Maintains updated student school records.
tudents'
5. Updates parents and students' progress regularly.
6. Supervises curricular and co-curricular projects and activities.
ort 7. Counsels and guides students.
8. Conduct action research.
9. Maintains cleanliness, safety and unkeep the classroom.
10. Participates in staff development, activities and utilizes KSAs gained from
seminars, trainings
11. Maintains and scholarship.
harmonious relationship with fellow teachers and other school
personnel as well as parents and stakeholders.
12. Supports activities of governmental and non-governmental organizations.
13. Does related works.
CS FORM No. 32
Revised 2017

Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
Lingayen

OATH OF OFFICE

I, RIZALYN C. CATALMA of
Kawayan St. Sablig, Anda, Pangasinan having been
appointed to the position of TEACHER I hereby
solemnly swear, that I will faithfully discharge to the best of my ability, the
duties of my present position and of all others that I may hereafter hold under
the Republic of the Philippines; that I will bear true faith and allegiance to the
same; that I will obey the laws, legal orders, and decrees promulgated by the
duly constituted authorities of the Republic of the Philippines; and that I impose
this obligation upon myself voluntarily, without mental reservation or purpose
of evasion.

SO HELP ME GOD.

RIZALYN C. CATALMA

Gov't ID:
ID Number:
Date Issued:

Subscribed and sworn to before me this day of

in LINGAYEN, PANGASINAN Philippines.
 SHEILA MARIE A. PRIMICIAS, CESO VI
Assistant Schools Division Superintendent
Officer-In-Charge
Office of the Schools Division Superintendent
CS Form No. 211
Revised 2017

MEDICAL CERTIFICATE
(For Employment)

INSTRUCTIONS
a. This medical certificate should be accomplished by a licensed government physician.
b. Attach this certificate to original appointment, transfer and reemployment.
c. The results of the following pre-employment medical/physical/mental examinations
must be attached to this form:
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

FOR THE PROPOSED APPOINTEE

NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS

CATALMA, RIZALYN CACHO

ADDRESS DEPED BOLINAO IS
SABLIG, ANDA, PANGASINAN
AGE SEX CIVIL STATUS PROPOSED POSITION

25 F SINGLE SUBSTITUTE TEACHER

FOR THE LICENSED GOVERNMENT PHYSICIAN

I hereby certify that I have reviewed and evaluated the attached examination results, personally examined
the above named individual and found him/her to be physically and medically £FIT / £UNFIT for employment.
SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE

AGENCY/Affiliation of Licensed Government Physician:

LICENSE NO. HEIGHT (M) WEIGHT (KG) BLOOD

Bare Foot Stripped TYPE
1.55 59 B'
OFFICIAL DESIGNATION DATE EXAMINED
CS Form No. 212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME FAJARDO
NAME EXTENSION (JR., SR) N/A
FIRST NAME RIZALYN N/A

MIDDLE NAME CATALMA

3. DATE OF BIRTH
(mm/dd/yyyy)
16. CITIZENSHIP FILIPINO
11/30/1995

4. PLACE OF BIRTH SABLIG, ANDA, PANGASINAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

17. RESIDENTIAL ADDRESS KAWAYAN ST.

6. CIVIL STATUS MARRIED
House/Block/Lot No. Street
SABLIG
Subdivision/Village Barangay
ANDA PANGASINAN
7. HEIGHT (m) 1.7
City/Municipality Province
8. WEIGHT (kg) 60 ZIP CODE 2405

9. BLOOD TYPE B+
18. PERMANENT ADDRESS KAWAYAN ST.
House/Block/Lot No. Street

10. GSIS ID NO. N/A SABLIG

Subdivision/Village Barangay
ANDA PANGASINAN
11. PAG-IBIG ID NO. 1212-7876-3371
City/Municipality Province

12. PHILHEALTH NO. 05-025626383-9 ZIP CODE 2405

13. SSS NO. 0111-8725949-8 19. TELEPHONE NO. N/A

14. TIN NO. 701-879-416-00- 20. MOBILE NO. 09483734002/09959702508

15 AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) rizahcatalma1130@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME FAJARDO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME JOSEPH N/A N/A

MIDDLE NAME RAMOS N/A N/A

OCCUPATION POLICE OFFICER N/A N/A

EMPLOYER/BUSINESS NAME PNP N/A N/A

BUSINESS ADDRESS Brgy.Aguit-itan,Calbayog City,Samar N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME CATALMA N/A N/A

NAME EXTENSION (JR., SR)
FIRST NAME MAC ARTHUR N/A N/A

MIDDLE NAME CORPUZ N/A N/A

25. MOTHER'S MAIDEN NAME N/A N/A

SURNAME CACHO N/A N/A

FIRST NAME FRANCING N/A N/A

MIDDLE NAME CAROLINO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE HIGHEST LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE UNITS
YEAR
ACADEMIC
LEVEL (Write in (Write in full) EARNED
GRADUATED
HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY Sablig Elementary School Elementary 6/3/2001 4/3/2008 N/A 2008 with Honor

SECONDARY /
VOCATIONAL Anda National High School Secondary 6/2/2008 4/1/2012 N/A 2012 with Honor

N/A N/A N/A N/A N/A N/A N/A

TRADE
COURSE
COLLEGE Asbury College Inc. Bachelor of Elementary Education 6/3/2013 4/1/2017 N/A 2017 N/A

GRADUATE STUDIES Colegio de Dagupan Masteral of Education 7/14/2018 10/26/2018 12 N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 07,2021

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

LET ( Licensure Examination for Teacher ) 77.8 09/24/2017 Baguio 1568997 11/30/2020

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet. GOV'T
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)
10/2/2021 PRESENT Teacher I Tondol Elementary School 23877.00 11-1 Permanent Yes

6/6/2017 2/4/2019 Teacher Creative Gems Learning Center 6000.00 N/A Contractual No

09/23/2019 10/31/2019 Substitute Teacher Toritori Elementary School 20754.00 N/A Substitute Yes

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JULY 07,2021

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)
VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To

Basic Computer Enhancement 10/13/2018 12/15/2018 80.0 Technical OBC Learning and Assessment Center

District Echo-Taining on the Development of Road Map and Balik Kasaysayan Conpendium 10/23/2019 10/25/2019 30.0 Supervisory
Anda Integrated School

GAD SENIOR CITIZEN TRAINING 2019 10/21/2019 10/21/19 10.0 Supervisory

Toritori Elementary School

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

(Continue on separate sheet if necessary)

N/A
MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
(Write in full)

N/A N/A N/A

N/A N/A N/A

 N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE JUNE 07,2021

CS FORM 212 (Revised 2017), Page 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending authority, or to the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:

36. 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:
________________________________
________________________________
37. 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 or If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the
last election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
If YES, give details (country):

40. 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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
If YES, please specify ID No:

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
CEZARDO C. LADIA CABUNGAN,ANDA,PANGASINAN 09772016418 3.5 cm. X 4.5 cm
(passport size)

GEMINA C. CELZO CONCORDIA,BOLINAO,PANGASINAN 9666476491 With full and handwritten

name tag and signature over
printed name
PERLITA O. EPETIA MACANDOCANDONG, ANDA,PANGASINAN 9076650720
Computer generated
42.
I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. I agree that any misrepresentation made in this document and its attachments shall cause the filing of administrative/criminal case/s against me.
or photocopied picture
is not acceptable

PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC ID

ID/License/Passport No.: 1568997

Signature (Sign inside the box)
 July 6, 2021
Date/Place of Issuance: 12/08/2017/BAGUIO CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

HON.MAYOR JOGANIE C. RARANG

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4