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
