CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s ag
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do

I. PERSONAL INFORMATION
2. SURNAME BANGLOY
NAME EXTENSION (JR., SR
FIRST NAME CARMELITA
MIDDLE NAME MANALILI
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) 07/14/1983 ✘ Filipino Dual Citizenship
by birth by
BUTUAY, JIMINEZ, MISAMIS
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate cou
OCCIDENTAL
please indicate the details.
5. SEX Male ✘ Female

Single ✘ Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S

Other/s: SINTOS SUBD. VILLA K

Subdivision/Village Ba
7. HEIGHT (m) 5'1 BUTUAN CITY AGUSAN
City/Municipality Pr
8. WEIGHT (kg) 60 ZIP CODE 8600
18. PERMANENT ADDRESS
9. BLOOD TYPE O
House/Block/Lot No. S

10. GSIS ID NO. 2003-485-810 SINTOS SUBD. VILLA K

Subdivision/Village Ba

11. PAG-IBIG ID NO. 183-000-649-750 BUTUAN CITY AGUSAN

City/Municipality Pr

12. PHILHEALTH NO. 180-000-462-339 ZIP CODE 8600

13. SSS NO. 082-291-211-4 19. TELEPHONE NO. N-O-N-E
14. TIN NO. 948-788-514 20. MOBILE NO. 09305172809
15. AGENCY EMPLOYEE NO. 423-5173 21. E-MAIL ADDRESS (if any) carmelita.bangloy@deped.gov.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME BANGLOY 23. NAME of CHILDREN (Write full name and list all)

NAME EXTENSION (JR., SR)

FIRST NAME JOVEN JOVEN JR. MANALILI BANGLOY
MIDDLE NAME DELA FUENTE
OCCUPATION JO-DRIVER
EMPLOYER/BUSINESS NAME DEPARTMENT OF AGRICULTURE
BUSINESS ADDRESS CAPITOL SITE, BUTUAN CITY
TELEPHONE NO. 342-4092
24. FATHER'S SURNAME MANALILI
NAME EXTENSION (JR., SR)
FIRST NAME DOMINADOR
 MIDDLE NAME VILIOTA
25. MOTHER'S MAIDEN NAME

SURNAME SUMAGANG
FIRST NAME LOURDES
MIDDLE NAME RESABA (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

SUMASAP ELEMENTARY
ELEMENTARY 1990 1996
SCHOOL
SCHOOL OF SAINT JOHN THE
SECONDARY /
VOCATIONAL 1996 2000
BAPTIST

TRADE BUKIDNON STATE COLLEGE

BACHELOR OF ELEMENTARY
COURSE
COLLEGE (EXTERNAL STUDIES 2001 2005
EDUCATION
CENTER)
SAINT JOSEPH INSTITUTE OF MASTER OF ARTS IN
GRADUATE STUDIES CAR
TECHNOLOGY EDUCATION
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM
L DATA SHEET
erience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

P3
Street
VILLA KANANGA
Barangay
AGUSAN DEL NORTE
Province

8600
P3
Street
VILLA KANANGA
Barangay
AGUSAN DEL NORTE
Province

N-O-N-E

09305172809

carmelita.bangloy@deped.gov.ph

DATE OF BIRTH (mm/dd/yyyy)

7/21/2015
 (Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

1996

2000

2005

parate sheet if necessary)

CS FORM 212 (Revised 2017), Page 1 of 4

IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if ap
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

LICENSURE EXAMINATION FOR

78% 8/14/2005 CAGAYAN DE ORO CITY 0904517
TEACHERS

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

1/28/2008 PRESENT TEACHER III DEPARTMENT OF EDUCATION P 23, 517.00 SG 13 PERMANENT

PLANNING, MONITORING AND PROJECT

10/03/2005 10/06/2006 DEVELOPMENT DIVISION STAFF DEPARTMENT OF AGRICULTURE P 10, 000.00 JOB ORDER
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)

YES

YES
arate sheet if necessary)

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/yyyy) NUMBER OF HOURS POSITION /
From To

N-O-N-E

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

SEVEN DAY REGIONAL TRAINING ON DEVELOPMENTALLY

APPROPRIATE PRACTICES IN EARLY LANGUAGE LITERACY 08/15/2017 08/21/2017 56
AND NUMERACY (DAP-ELLN)

TEN DAY REGIONAL ENHANCEMENT TRAINING ON EARLY

07/13/2015 07/22/2015 80
LITERACY AND NUMERACY

3 DAY DIVISION TRAINING ON CAPABILITY BUILDING FOR

10/20/2014 10/22/2014 24
ELEMENTARY MATHEMATICS TEACHERS

MTB-MLE INSTRUCTIONAL MATERIAL DEVELOPMENT FOR

8/11/2014 08/28/2014 48
GRADES I-III

TWO DAY DIVISION SEMINAR WORKSHOP ON BEGINNING

05/14/2012 5/18/2012 16
READING FOR GRADE ONE TEACHERS

MASS TRAINING FOR GRADE ONE TEACHERS ON THE

IMPLEMENTATION FOR K-12 BASIC EDUCATION 5/14/2012 5/18/2012 40
CURRICULUM

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
COMPUTER LITERATE

COOKING

DRIVING

VOLLEYBALL

BASEBALL

(Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

REGION

REGION

DIVISION

DIVISION

DIVISION

DIVISION

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
eparate sheet if necessary)

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,
a. within the third degree? YES ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

If YES, give details:

________________________________

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:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ROSEMARIE B. BAHAN MAON ELEMENTARY SCHOOL 09199786873 3.5 cm. X 4.5 cm
(passport size)

MARILYN L. PASOK BAAN ELEMENTARY SCHOOL 09197806317 With full and handwritten
name tag and signature over
printed name
FROILAN S. OLIT ANTICALA ELEMENTARY SCHOOL 09487981138
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
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.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: PRC
ID/License/Passport No.: 0904517 Signature (Sign inside the box)

Date/Place of Issuance: 07/14/2017/BUTUAN CITY Date Accomplished Right Thumbmark

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 o

 If YES, give details (country):

, affiant exhibiting his/her validly issued government ID as indicated above.

CS FORM 212 (Revised 2017), Page 4 of 4