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. (D

I. PERSONAL INFORMATION
2. SURNAME
NAME EXTENSION (JR., SR
FIRST NAME

MIDDLE NAME

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) Filipino Dual Citizenship
by birth by
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male Female

Single Married 17. RESIDENTIAL ADDRESS

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

Other/s:
Subdivision/Village Ba
7. HEIGHT (m)
City/Municipality P
8. WEIGHT (kg) ZIP CODE
18. PERMANENT ADDRESS
9. BLOOD TYPE
House/Block/Lot No.

10. GSIS ID NO.

Subdivision/Village Ba

11. PAG-IBIG ID NO.

City/Municipality P

12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 19. TELEPHONE NO.

14. TIN NO. 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME

NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessar

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

ELEMENTARY

SECONDARY
VOCATIONAL /

TRADE
COLLEGE
COURSE

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE CS FORM 212 (Re

L DATA SHEET
rience 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:

Street

Barangay

Province

Street

Barangay

Province

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR ACADEMIC
GRADUATED HONORS
RECEIVED
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 applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
LICENSURE EXAMINATION FOR TEACHERS
75% 3/4/2011 DAVAO CITY 1095827 04/25/2011
(ELEMENTARY LEVEL)

(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. GOV'T
SERVICE
28. INCLUSIVE DATES SALARY/ JOB/ PAY
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in (Write in full/Do not SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
full/Do not abbreviate) abbreviate) INCREMENT
From To (Y/
N)
1/1/2017 TO DATE TEACHER I DEPARTMENT OF EDUCATION - COTABATO CITY 19853.00 11-2 PERMANENT Y

1/1/2016 12/31/16 TEACHER I DEPARTMENT OF EDUCATION - COTABATO CITY 19286.00 11-2 PERMANENT Y

08/15/15 12/31/15 TEACHER I DEPARTMENT OF EDUCATION - COTABATO CITY 18735.00 11-2 PERMANENT Y

08/15/12 08/14/15 TEACHER I DEPARTMENT OF EDUCATION - COTABATO CITY 18549.00 11-1 PERMANENT Y

6/6/2011 8/14/2012 KINDERGARTEN TEACHER DEPARTMENT OF EDUCATION - COTABATO CITY 6000.00 N/A CONTRACTUAL Y

1/6/2009 3/31/2011 KINDERGARTEN TEACHER DEPARTMENT OF EDUCATION - COTABATO CITY 3000.00 N/A CONTRACTUAL Y

5/27/2004 10/26/2004 SERVICE CREW MISTER DONUT OF COTABATO 3600.00 N/A CONTRACTUAL N

1/4/2002 8/31/2002 SERVICE CREW JOLLIBEE COTABATO PLAZA 3600.00 N/A CONTRACTUAL N

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 27, 2017 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 / N
From To

WEMENS CLUB, GOV GUTTIEREZ AVE COTABATO CITY 1/1/2015 3/7/2017 4HOURS PR

(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/ S
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

KINDERGARTEN PEDAGOGY CUM INSTRUCTIONAL MATERIAL (FIRST QUARTER)05/24/2018 05/25/2018 24 TECHNICAL DEPARTMENT
DVISION TRAINING ON THE KINDERGARTEN PEDAGOGY CUM INSTRUCTIONAL
12/1/2016 05/13/2016 24 TECHNICAL DEPARTMENT
MATERIALS (1ST QUARTER MAKING)
TRAINING ON DEVELOPMENTALLY APPROPRIATE PRACTICES CUM MAKING
INSTRUCTIONAL MATERIALS FOR READING AND MATHEMATICS SUBJECTS K 5/11/2016 05/13/2016 10 TECHNICAL DEPARTMENT
TO3

INTERNATIONAL SEMINAR WORKSHOP ON EARLY CHILDHOOD EDUCATION IN

04/21/2016 04/23/2016 24 TECHNICAL DEPARTMENT
WORK PLACE

DIVISION TRAINING ON KINDERGARTEN CATCH UP PROGRAM

ADMINISTRATION OF THE MIN & YEAR ED ASSESMENT CUM PROGRAM 04/20/2014 04/22/2014 16 TECHNICAL DEPARTMENT
IMPLEMENTATION REVIEW

SCHOOL ORIENTATION TRAINING ON THE BASIC AND HIV AND AIDS

12/3/2013 12/7/2013 16 TECHNICAL DEPARTMENT
EDUCATION IN THE WORKPLACE

TRAINING ON BASIC LEADERSHIP COURSE 09/13/2013 09/14/2013 16 TECHNICAL DEPARTMENT

TRAINING WORKSHOP ON TEACHER INDUCTION PROGRAM FOR GEGINNING
05/28/2013 05/30/2013 16 TECHNICAL DEPARTMENT
TEACHERS
DIVISION TRAINING OF KINDERGARTEN REGULAR TEACHER ON THE
05/23/2013 05/25/2013 24 TECHNICAL DEPARTMENT
NATIONAL KINDERGARTEN CURRICULUM

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSH
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
WATCHING MOVIES AND CURRENT NEWS

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 27, 2017

PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

PRESIDENT

arate sheet if necessary)

OGRAMS ATTENDED
ve (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

DEPARTMENT OF EDUCATION

arate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write in
full)
arate 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 ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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 NO
YES ✘
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
MAGUINDA BULARON ADLAON TORONTO, ONTARIO 421-25-74 3.5 cm. X 4.5 cm
(passport size)

LARA BEA AGNO PACAÑA TORONTO, ONTARIO 421-25-75 With full and handwritten
name tag and signature over
printed name
DEPARTMENT OF EDUCATION -
CONCEPCION F. BALAWAG, AL-DADJA COTABATO CITY
421-25-74 Computer generated
or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, 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 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: GSIS

ID/License/Passport No.: 006-0179-5887-3

Signature (Sign inside the box)
JUNE 8, 2017
Date/Place of Issuance: 2015/COTABATO 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 of

 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