Inbound 8304520867022952096
Inbound 8304520867022952096
Inbound 8304520867022952096
212
Revised 2017
I. PERSONAL INFORMATION
2. SURNAME FLORIA
NAME EXTENSION (JR., SR)
FIRST NAME STEVEN CLAUDE
MIDDLE NAME
LOPEZ
3. DATE OF BIRTH
(mm/dd/yyyy)
5/10/1999 16. CITIZENSHIP Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH TUGUEGARAO CITY If holder of dual citizenship,
Pls. indicate country:
please indicate the details.
5. SEX Male Female
15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) sclfloria1@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME FLORIA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH
(mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME
CRYSTAL JOY SAGE LUIS R. FLORIA 8/1/2019
MIDDLE NAME RAMOS
OCCUPATION HOUSEWIFE
EMPLOYER/BUSINESS NAME N/A
BUSINESS ADDRESS N/A
TELEPHONE NO. 9278719064
24. FATHER'S SURNAME FLORIA
NAME EXTENSION (JR., SR)
FIRST NAME PHILIP
MIDDLE NAME
SURNAME FLORIA
MIDDLE NAME
LOPEZ (Continue on separate sheet if necessary)
ELEMENTARY ALCALA EAST CENTRAL SCHOOL N/A 2006 2012 N/A 2012 N/A
SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) DATE OF LICENSE (if applicable)
RATING
UNDER SPECIAL LAWS/ CES/ CSEE EXAMINATION PLACE OF EXAMINATION / CONFERMENT Date
(If NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE Applicable) / of
CONFERMENT Validit
y
CAREEER CIVIL SERVICE PROFESSIONAL
81.8 MARCH 26, 2023 ATULAYAN, TUGUEGARAO CITY
EXAMINATION
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
SALARY/ JOB/ PAY
28. INCLUSIVE DATES POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY SERVICE
GRADE (if
(mm/dd/yyyy) MONTHL STATUS OF
(Write in (Writ applicable)& STEP
Y APPOINTMENT
full/Do e (Format "00-
From To SALARY 0")/
not abbreviate) in full/Do not abbreviate)
INCREMENT
SIGNATURE DATE
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/ NUMBER OF HOURS POSITION / NATURE OF WORK
yyyy)
Fro To
m
COMMUNICATION SKILLS
INTERPERSONAL SKILLS
DATA GATHERING
SPORTS
SIGNATURE DATE
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, YES NO
a. within the third degree?
YES NO
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?
YES NO
37. Have you ever been separated from the service in any of the following modes: YES NO
resignation, retirement, dropped from the rolls, dismissal, termination, end of term, If YES, give details:
finished contract or 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
YES NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period YES NO
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 YES NO
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:
YES NO
a.
Are you a member of any indigenous group? If YES, please specify:
YES NO
b.
Are you a person with disability? If YES, please specify ID No:
YES 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)
Computer
ROWELL JHAY SOLIVEN, LPT ALCALA, CAGAYAN 9272635494 generated or
photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, is not acceptable
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 PHOTO
the filingIssued
Government of administrative/criminal
ID (i.e.Passport, GSIS, SSS, PRC, case/s against
Driver's License, etc.) me.
Date/Place of Issuance:
Date Right Thumbmark
Accomplished
SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.
Person Administering
Oath
CS FORM 212 (Revised 2017), Page 4 of 4