Lorna Mae Escabusa

CS FORM 212 (Revised 2005) Unique Applicant Number PERSONAL DATA SHEET Print legibly. Mark appropriate boxes with " T- 1. CS ID No. " and use separate sheet if necessary. (to be filled up by CSC) I. PERSONAL INFORMATION ESCABUSA 2. SURNAME FIRST NAME LORNA MAE MIDDLE NAME ECHEM 3. NAME EXTENSION (e.g. Jr., Sr.) 09 / 17 / 1990 4. DATE OF BIRTH (mm/dd/yyyy) 16. RESIDENTIAL ADDRESS TAMBO MACASANDIG CAGAYAN DE ORO CITY 5. PLACE OF BIRTH MALE 6. SEX block 42, house 6 phase pagatpat, CAGAYAN DE ORO CITY (Capital), MISAMIS ORIENTAL FEMALE 7. CIVIL STATUS ZIP CODE Single Widowed Married Separated Annuled Others, specify _________ 9000 17. TELEPHONE NO. none 18. PERMANENT ADDRESS block 42, house 6 phase pagatpat, CAGAYAN DE ORO CITY (Capital), MISAMIS ORIENTAL 8. CITIZENDSHIP FILIPINO 9. HEIGHT (m) 1.58496 10. WEIGHT (kg) 47 11. BLOOD TYPE B+ 19. TELEPHONE NO. none 12. GSIS ID NO. none 20. EMAIL ADDRESS (if any) - 13. PAGIBIG ID NO. none 21. CELLPHONE NO. (if any) - 14. PHILHEALTH NO. - 22. AGENCY EMPLOYEE NO. none 15. SSS NO. - 23. TIN - ZIP CODE 9000 II. FAMILY BACKGROUND 24. SPOUSE'S SURNAME FIRST NAME MIDDLE NAME Escabusa 25. NAME OF CHILD (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy) Joel JESSEL MAE E. ESCABUSA 04 / 08 / 2011 Beron JANELLE E. ESCABUSA 05 / 17 / 2014 Self-employed OCCUPATION EMPLOYER/BUS. NAME BUSINESS ADDRESS - TELEPHONE NO. (Continue on separate sheet if necessary) 26. FATHER'S SURNAME Echem FIRST NAME Vicente MIDDLE NAME Rabanes 27. MOTHER'S MAIDEN NAME MOTHER'S SURNAME Tiempo FIRST NAME Jossie MIDDLE NAME Saransa III. EDUCATIONAL BACKGROUND 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 From To ELEMENTARY Macasandig Elementary School 2003 - - SECONDARY Cagayan de Oro National High School 2007 - - VOCATIONAL/ TRADE COURSE Pilgrim Christian College Construction Painting NCII 2014 - - COLLEGE Pilgrim Christian College Bachelor of Elementary Education 2012 - - GRADUATE STUDIES Lourdes College IV. CIVIL SERVICE ELIGIBILITY ESCABUSA, LORNA MAE ECHEM - T- Masteral Arts Education 12 SCHOLARSHIP/ ACADEMIC HONORS RECEIVED 2014 CS FORM 212 (Revised 2005), Page 1 of 3 29. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEE RATING LET (LICENSURE EXAMINATION FOR TEACHER) LICENSE (if applicable) DATE OF EXAMINATION / CONFERMENT 76.40% 09 / 01 / 2012 PLACE OF EXAMINATION / CONFERMENT NUMBER Cagayan de Oro City - DATE OF RELEASE 03/01/2013 V. WORK EXPERIENCE 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 06/15/2015 03/30/2016 Pre school teacher Niña Maria Learning Center 6,000 0-0 teacher No 09/02/2013 10/31/2013 teacher 1 Department of EDUCATION 16, 450 0-0 substitute Yes 08/02/2013 08/30/2013 teacher 1 Department of EDUCATION 16, 450 0-0 substitute Yes 06/07/2003 08/01/2013 teacher 1 Department of EDUCATION 16, 450 0-0 substitute Yes VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S 31. INCLUSIVE DATES (mm/dd/yyyy) NAME & ADDRESS OF ORGANIZATION (Write in full) From To NUMBER OF HOURS POSITION / NATURE OF WORK NUMBER OF HOURS CONDUCTED/ SPONSORED BY (Write in full) 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) From To Construction Painting NCII 09 / 01 / 2014 09 / 24 / 2014 Mid Year in Service Trainintg 10 / 29 / 2013 10 / 31 / 2013 Basic Computer literacy 01 / 01 / 2014 12 / 03 / 2014 136 Pilgrim ChristiaN College Alternative Learning System VIII. OTHER INFORMATION 33. SPECIAL SKILLS / HOBBIES: 34. NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full) 35. MEMBERSHIP IN ASSOCIATION / ORGANIZATION (Write in full) House keeping cooking basic Carpentry House keeping cooking basic Carpentry ESCABUSA, LORNA MAE ECHEM - T- 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): 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? b. Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed? YES NO If YES, give details: _____________________________________ _____________________________________ _____________________________________ 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 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 regulation by any court or tribunal? 39. 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? YES NO If YES, give details: _____________________________________ _____________________________________ YES NO 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 Andres Batica IV Pagatpat Cagayan De Oro CIty Jesica Joy GD. Hinacay City Central School Laura A. Tantoy Pilgrim Christian College TEL. NO- 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. I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that this information shall remain confidential. X PHOTO - COMMUNITY TAX CERTIFICATE NO. Pagatpat Cagayan de Oro City ISSUED AT SIGNATURE (Sign inside the box) - 01 / 23 / 2019 ISSUED ON (mm/dd/yyyy) DATE ACCOMPLISHED ESCABUSA, LORNA MAE ECHEM - T- RIGHT THUMBMARK CS FORM 212 (Revised 2005), Page 3 of 3