MC Pds
MC Pds
MC Pds
212
Revised 2017
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A N/A N/A
OCCUPATION N/A
SURNAME YAP
SAINT ANTHONY'S COLLEGE GRADE SCHOOL 2002 2004 GRADE 2 N/A N/A
ELEMENTARY ELEMENTARY
DELEGATE ANGEL SALAZAR JR. MEMORIAL
SCHOOL
2004 2008 N/A 2008 N/A
SECONDARY ANTIQUE NATIONAL SCHOOL HIGH SCHOOL 2008 2012 N/A 2012 N/A
VOCATIONAL /
N/A N/A N/A N/A N/A N/A N/A
TRADE COURSE
COLLEGE UNIVERSITY OF ANTIQUE BACHELOR OF SCIENCE MAJOR IN MARKETING 2012 2017 N/A 2017 N/A
COOKING
35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
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 YES ✘ NO
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, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or phased If YES, give details:
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 YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
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? YES ✘ NO
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? YES ✘ NO
If YES, please specify:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No: _________________________
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No: _________________________
MRS. MA. TERESA S. TUNGUIA SAN JOSE, ANTIQUE 09176683868 With full and handwritten
name tag and signature over
printed name
MRS. ELEANORE DAGALA DAO, ANTIQUE 09177075121
Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and is not acceptable
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 PHOTO
administrative/criminal case/s against me.
ID/License/Passport No.:
Signature (Sign inside the box)
May 20,2020
Date/Place of Issuance:
Date Accomplished Right Thumbmark
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.