Professional Documents
Culture Documents
I. PERSONAL INFORMATION
2. SURNAME PAGLUMOTAN
FIRST NAME KHEN MARK
MIDDLE NAME TOLEDO 3. NAME EXTENSION (e.g. Jr., Sr.)
FIRST NAME
MIDDLE NAME
OCCUPATION
EMPLOYER/BUS. NAME
BUSINESS ADDRESS
TELEPHONE NO.
TALUBANGI ELEMENTARY
ELEMENTARY 2009 2003 2009
SCHOOL
VOCATIONAL/ TRADE
COURSE
BACHELOR IN
CEBTRAL PHILIPPINES
COLLEGE PHYSICAL 2017 2013 2017 CUM LAUDE
STATE UNIVERSITY
EDUCATION
GRADUATE STUDIES
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")
PAGLUMOTAN, KHEN MARK TOLEDO - T15255526 CS FORM 212 (Revised 2005), Page 2 of 3
36. Are you related by consanguinity or affinity to any of the following :
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:
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
PAGLUMOTAN, KHEN MARK TOLEDO - T15255526 CS FORM 212 (Revised 2005), Page 3 of 3