Personal Data Sheet (Revised 2005)

C1CS FORM 212 (Revised 2005)PERSONAL DATA SHEETPrint legibly. Mark appropriate boxes with " " and use separate sheet if necessary.1. CS ID No.(to be filled up by CSC)I. PERSONAL INFORMATION2.SURNAMES | A | L | E | N | G | A | | | | | | | | | | | | | | | | | | | | | | | | |FIRST NAMEJ | E | R | I | C | O | | | | | | | | | | | | | | | | | | | | | | | | | |MIDDLE NAMED | I | P | A | S | U | P | I | L | | | | | | | | | | | | | | | | | | | | | | |3. NAME EXTENSION (e.g. Jr., Sr.)N/A4.DATE OF BIRTH (mm/dd/yyyy)08/22/198416. RESIDENTIAL ADDRESS39 MANUEL L. QUEZON STREET, LOWER BICUTAN, TAGUIG, METRO MANILA5.PLACE OF BIRTHMANDALUYONG6.SEX7.CIVIL STATUSZIP CODE163217. TELEPHONE NO.(02) 837-567718. PERMANENT ADDRESS39 MANUEL L. QUEZON STREET, LOWER BICUTAN, TAGUIG, METRO MANILA8.CITIZENSHIPFILIPINO9.HEIGHT (m)1.63 METERS10.WEIGHT (kg)61 KILOGRAMSZIP CODE163211.BLOOD TYPE19. TELEPHONE NO.(02) 837-567712.GSIS ID NO.20. E-MAIL ADDRESS (if any)JERICOSALENGA@GMAIL.COM13.PAG-IBIG ID NO.121-123-462-96021. CELLPHONE NO. (if any)0915551112714.PHILHEALTH NO.0105-1939-258022. AGENCY EMPLOYEE NO.SSS NO.34-4774954-923. TIN457-927-072II. FAMILY BACKGROUND24.SPOUSE'S SURNAMEN/A25. NAME OF CHILD (Write full name and list all)DATE OF BIRTH (mm/dd/yyyy)FIRST NAMEN/A/ /MIDDLE NAME/ /OCCUPATION/ /EMPLOYER/BUS. NAME/ /BUSINESS ADDRESS/ /TELEPHONE NO./ /(Continue on separate sheet if necessary)/ /26.FATHER'S SURNAMESALENGA/ /FIRST NAMEROGELITO/ /MIDDLE NAMEPAULE/ /27.MOTHER'S MAIDEN NAME/ /SURNAMEDIPASUPIL/ /FIRST NAMEANGELITA/ /MIDDLE NAMEDOMINGO(Continue on separate sheet if necessary)III. EDUCATIONAL BACKGROUND28.LEVELNAME 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 ATTENDANCESCHOLARSHIP/ ACADEMIC HONORS RECEIVEDFromToELEMENTARYCOLEGIO DE STA. ANAPRIMARY1996GRADE 6 - ELEMENTARY19931996DIPLOMASECONDARYSAN BEDA COLLEGE - HIGH SCHOOLINTERMEDIATE20014TH YEAR - HIGH SCHOOL19962001DIPLOMA, ACAD. DISTINCTIONVOCATIONAL / TRADE COURSEN/ACOLLEGEDE LA SALLE UNIVERSITYBA PSYCH AND BSC LEGAL MGT2005BACHELOR OF ARTS/COMM.20012005DIPLOMAGRADUATE STUDIESSAN BEDA COLLEGE ALABANG - SCHOOL OF LAWBACHELOR OF LAWS2014BACHELOR OF LAWS20092013DIPLOMA(Continue on separate sheet if necessary)Page 1 of 4

AnnulledOthers, specify ___________SingleMarriedWidowedSeparatedMaleFemale

C2IV. CIVIL SERVICE ELIGIBILITY29.CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ CES/ CSEERATINGDATE OF EXAMINATION / CONFERMENTPLACE OF EXAMINATION / CONFERMENTLICENSE (if applicable)NUMBERDATE OF RELEASERA 1080 (BAR)76.00%08/01/2013UNIVERSITY OF STO. TOMAS, ESPANA MANILA630102014CAREER SERVICE (Civil Service Elegibility)PASSED04/01/2014QUEZON CITY2014REAL ESTATE BROKERS EXAM78.00%05/24/2015COLLEGE OF THE HOLY SPIRIT, MENDIOLA MANILA2015(Continue on separate sheet if necessary)V. WORK EXPERIENCE (Include private employment. Start from your current work)30.INCLUSIVE DATES (mm/dd/yyyy)POSITION TITLE (Write in full)DEPARTMENT / AGENCY / OFFICE / COMPANY (Write in full)MONTHLY SALARYSALARY GRADE & STEP INCREMENT (Format "00-0")STATUS OF APPOINTMENTGOV'T SERVICE (Yes / No)FromTo05/25/2015PRESENTRETAINED ASSOCIATE COUNSELGIMENEZ LAW OFFICEPHP35000PERMANENTNO08/04/201502/27/2015ASSOCIATE LEGAL COUNSELHECHANOVA BUGAY VILCHEZ ANDAYA RACADIOPHP32000PROBATIONARYNO01/27/201407/31/2015UNDERBAR ASSOCIATECAMACHO AND ASSOCIATESPHP25000PROBATIONARYNO06/27/200309/22/2003ON THE JOB TRAINEEOFFICE OF THE SOLICITOR GENERALN/AOJTYES/ // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // // /(Continue on separate sheet if necessary)CS FORM 212 (Revised 2005), Page 2 of 4

C3VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S31.NAME & ADDRESS OF ORGANIZATION (Write in full)INCLUSIVE DATES (mm/dd/yyyy)NUMBER OF HOURSPOSITION / NATURE OF WORKFromToDEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT11/28/201311/28/20139REPACKER OF RELIEF GOODSBUREAU OF JAIL MANAGEMENT AND PENOLOGY07/07/190507/07/190560STUDENT LEGAL/ // // // // // /(Continue on separate sheet if necessary)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)NUMBER OF HOURSCONDUCTED/ SPONSORED BY (Write in full)FromToREAL ESTATE BROKERS LECTURE SERIES02/21/201505/18/2015120CITY OF TAGUIG REAL ESTATE BOARD/ // // // // // // // // // // // // // // // // // // // // // // // // // // // /(Continue on separate sheet if necessary)VIII. OTHER INFORMATION33.SPECIAL SKILLS / HOBBIES:34.NON-ACADEMIC DISTINCTIONS / RECOGNITION: (Write in full)35.MEMBERSHIP IN ASSOCIATION/ORGANIZATION (Write in full)LEGAL RESEARCHINTEGRATED BAR OF THE PHILIPPINESMUSICCITY OF TAGUIG REAL ESTATE BOARDTENNIS(Continue on separate sheet if necessary)CS FORM 212 (Revised 2005), Page 3 of 4

C436.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?If YES, give details: _____________________________________ _____________________________________ _____________________________________b.Within the fourth degree (for Local Government Employees): appointing authority or recommending authority where you will be appointed?If YES, give details: _____________________________________ _____________________________________ _____________________________________37a. Have you ever been formally charged?If YES, give details: ________________________________ ________________________________b. Have you ever been guilty of any administrative offense?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?If YES, give details: ________________________________ ________________________________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?If YES, give details: ________________________________ ________________________________40.Have you ever been a candidate in a national or local election (except Barangay election)?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?If YES, please specify: ____________________b.Are you differently abled?If YES, please specify: ____________________c.Are you a solo parent?If YES, please specify: ____________________42.REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)NAMEADDRESSTEL. NO.JESSIE JOHN P. GIMENEZSALCEDO VILLAGE, MAKATI845-1199GINO BAUTISTAARNAIZ AVENUE, MAKATI0917-8799258RODINIL BUGAYARNAIZ AVENUE, MAKATI0917-701640843.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.PHOTOCOMMUNITY TAX CERTIFICATE NO.ISSUED ATSIGNATURE (Sign inside the box)/ /06/02/2015ISSUED ON (mm/dd/yyyy)DATE ACCOMPLISHEDRIGHT THUMBMARKCS FORM 212 (Revised 2005), Page 4 of 4

ID picture taken within the last 6 months3.5 cm. X 4.5 cm(passport size)

Computer generated or xerox copy of picture is not acceptableYESNOYESNOYESNOYESNOYESNOYESNOYESNOYESNOYESNOYESNO

LookupYes/NoCstatGenderYesSingleMaleNoMarriedFemaleSeparatedWidowed