CS FORM 212 (Revised 2005)

Unique Applicant Number

PERSONAL DATA SHEET T15347061

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 BALAGTAS
FIRST NAME LEO
MIDDLE NAME GUSTO 3. NAME EXTENSION (e.g. Jr., Sr.)

16. RESIDENTIAL ADDRESS Maruglo, CAPAS, TARLAC

4. DATE OF BIRTH (mm/dd/yyyy) 03 / 23 / 1996
5. PLACE OF BIRTH Maruglo Capas Tarlac
6. SEX MALE FEMALE
7. CIVIL STATUS
Single Widowed ZIP CODE 2315
Married Separated
17. TELEPHONE NO.
Annuled Others, specify
_________ 18. PERMANENT ADDRESS Maruglo, CAPAS, TARLAC

8. CITIZENDSHIP Filipino
9. HEIGHT (m) 5’6
10. WEIGHT (kg) 62 ZIP CODE 2315
11. BLOOD TYPE A+ 19. TELEPHONE NO.

12. GSIS ID NO. 20. EMAIL ADDRESS (if any) balagtasleo2396@gmail.com

13. PAGIBIG ID NO. 21. CELLPHONE NO. (if any) 09071299808
14. PHILHEALTH NO. 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 Balagtas

FIRST NAME Pedro

MIDDLE NAME Ramos

27. MOTHER'S MAIDEN NAME

MOTHER'S SURNAME Gusto

FIRST NAME Estelita

MIDDLE NAME Pentecoates

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

ELEMENTARY Maruglo Elementary School 2008 2002/6/8 2008/27/3

SECONDARY O'donnell High School Annex 2012 2008/6/10 2012/5/4

VOCATIONAL/ TRADE
COURSE

Bachelor of
COLLEGE Tarlac State University 2017 2012/6/10 2017/6/15
Secondary Education

GRADUATE STUDIES

IV. CIVIL SERVICE ELIGIBILITY

BALAGTAS, LEO GUSTO - T15347061 CS FORM 212 (Revised 2005), Page 1 of 3

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
76,00 09 / 24 / 2017 Baguio 1582207 12/16/2017

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

United Nations Association of the

United Nations International Youth Day 08 / 25 / 2018 08 / 25 / 2018
Philippines

Electronic Producs Assembly and Servicing NCII 08 / 03 / 2018 10 / 15 / 2018 260 TESDA

Presidential Commission for the

Livelihood Training on Meat Processing 10 / 11 / 2017 10 / 11 / 2017 8
Urban Poor

Regional Training-Workshop on Idegenous Peoples Education Cultural Depaetment of Education Region

09 / 24 / 2017 09 / 27 / 2017
Standards III Central Luzon

Department of Interior and Local

Task Force on Youth 05 / 28 / 2017 05 / 30 / 2017 24
Government

Experiential Learning 04 / 04 / 2017 04 / 21 / 2017 108 Tarlac State University

Decagon: Gain, Accur, Nurture 11 / 12 / 2016 01 / 28 / 2017 80 Tarlac State University

Tripad: Plan, Assess, Direct 08 / 24 / 2016 08 / 26 / 2016 24 Tarlac State University

Ethical Standards For Educators 04 / 29 / 2016 04 / 02 / 2006 8 Tarlac State University

Teaching Competencies Standards Framework 07 / 26 / 2012 07 / 26 / 2012 8

VIII. OTHER INFORMATION

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

BALAGTAS, LEO GUSTO - T15347061 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:ABELLEN TRIBE
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.

Mr. Jaime Gawat Maruglo, Capas, Tarlac 09071299808

Prof. Ferrer C. Douglas Concepcion, Tarlac 09325473345

Dr. Cythia G. Quiambao Tarlac City 09322046898

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

30416259

COMMUNITY TAX CERTIFICATE NO.

Capas Tarlac

ISSUED AT SIGNATURE (Sign inside the box)

2019-01-21 01 / 29 / 2019

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

BALAGTAS, LEO GUSTO - T15347061 CS FORM 212 (Revised 2005), Page 3 of 3