CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation 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 BACONGUIS

FIRST NAME FLORINDA

MIDDLE NAME WACDASAN

3. DATE OF BIRTH
(mm/dd/yyyy) 1/16/1981 16. CITIZENSHIP ✘ Filipino Dual Citizenship
FILIPINO by birth by
4. PLACE OF BIRTH LINABO MALAYBALAY CITY If holder of dual citizenship, Pls. indicate count
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS P

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. S
LIN
Other/s:
Subdivision/Village Bar
MALAYBALAY CITY BUK
7. HEIGHT (m) 5'3
City/Municipality Pro
8. WEIGHT (kg) 65KG ZIP CODE 8700

18. PERMANENT ADDRESS P

9. BLOOD TYPE TYPE ''A''
House/Block/Lot No. S
LIN
10. GSIS ID NO. 2005318583
Subdivision/Village Bar
MALAYBALAY CITY
11. PAG-IBIG ID NO. 1820-0016-6684
City/Municipality Pro

12. PHILHEALTH NO. 15-200417616-7 ZIP CODE 8700

13. SSS NO. 08-2535606-5 19. TELEPHONE NO. N/A

14. TIN NO. 946-563-930 20. MOBILE NO. 09351146880

15. AGENCY EMPLOYEE NO.
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME
FIRST NAME
17-042 21. E-MAIL ADDRESS (if any) N/A
N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR) MICAEL DANE FLORENCE BACONGUIS

MIDDLE NAME

OCCUPATION GOVERNMENT EMPLOYEE

EMPLOYER/BUSINESS NAME LGU MALAYBALAY

BUSINESS ADDRESS CASISANG MALYBALAY CITY

TELEPHONE NO. 9759713369

24. FATHER'S SURNAME BACONGUIS

FIRST NAME DANILO

MIDDLE NAME UNABIA

25. MOTHER'S MAIDEN NAME

SURNAME WACDASAN

FIRST NAME FLORITA

MIDDLE NAME DINGANON (Continue on separate sheet if necessar

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY LINABO CENTRAL ELEM.SCHOOL N/A 1988 1994 N/A

SECONDARY /
VOCATIONAL MANAGOK NATIONAL HIGH SCHOOL N/A 1994 1998 N/A

N/A

TRADE
COLLEGE BUKIDNON STATE COLLEGE BACHELOR IN ELEMENTARY EDUCATION 2002 2006 GRADUATED

GRADUATE STUDIES N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE January

CS FOR
L DATA SHEET
perience Sheet shall cause the filing of administrative/criminal case/s against the person

BEFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

Dual Citizenship

by naturalization

Pls. indicate country:

P-2
Street
LINABO
Barangay
BUKIDNON
Province
8700

P-2
Street
LINABO
Barangay
BUKIDNON
Province

N/A

09351146880

N/A

DATE OF BIRTH (mm/dd/yyyy)

10/14/1999

(Continue on separate sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC HONORS
RECEIVED

1994

1998
 2006

separate sheet if necessary)

January 24, 2018

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

N/A

(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

11/2/2017 TO DATE BAND MASTER CITY GOVERNMENT OF MALAYBALAY 16986.00 Permanent

7/9/2007 10/30/2017 ADMINISTRATIVE AIDE CITY GOVERNMEMNT OF MALAYBALAY 404.09 PER JO

DAY
 (Continue on separate sheet if necessary)

SIGNATURE DATE 1-24-2018

CS FORM 212 (Revised 20
 LICENSE (if applicable)

Date of
Validity

arate sheet if necessary)

GOV'T
SERVICE

(Y/
N)
Y

Y
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/A

(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

MAYOR'S STAFF RE-ORIENTATION,PERFORMANCE DEVELOPMENT PROGRAM 3/30/2012 3/31/2012 16 HOURS ORIENTATION

CITY MAYOR'S OFFICE PERFORMANCE COMMITMENT REVIEW FORMULATION AND

2/12/2005 1/13/2015 16 HOURS TECHNICAL
TEAM BUILDING
1 TEAM, 1 VISION, 1 GOAL:CMO YEAR-END ASSESMENT & 2017 GOAL SETTING OF THE
2/14/2017 2/17/2017 32HOURS TECHNICAL
CITY MAYOR'S OFFICE

TRAINING WORKSHOP ON EFFECTIVE COMMUNICATION 8/4/2016 8/4/2016 8HOURS TECHNICAL

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

SINGING, DANCING N/A

 (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)

CITY MAYOR'S OFFICE

CITY MAYOR'S OFFICE

CITY MAYOR'S OFFICE

CITY MAYOR'S OFFICE

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)

N/A
eparate sheet if necessary)

1-24-2018
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
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: LI007

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ROLAND F. DETICIO CASISANG MALAYBALAY CITY N/A 3.5 cm. X 4.5 cm
(passport size)

JAMOROL JERSON CLARO M. RECTO MALAYBALAY CITY N/A With full and handwritten
name tag and signature over
printed name
MANUEL EVANGELISTA LINABO MALAYBAL;AY CITY N/A
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: ID OFFICE
FLORINDA W.BACONGUIS
ID/License/Passport No.: 17-042 Signature (Sign inside the box)
1-24-2018
Date/Place of Issuance: 11-15-2017
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