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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 agai
person 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 not fill up. For CSC

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

MIDDLE NAME MIPANGCAT


3. DATE OF BIRTH
(mm/dd/yyyy) NOV. 23, 1983 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalizati
4. PLACE OF BIRTH OLD CAPITOL, MARAWI CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

✘ Single Married 17. RESIDENTIAL ADDRESS 090 OLD CAPITOL


6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
MATAMPAY
Other/s:
Subdivision/Village Barangay
MARAWI CITY LANAO DEL SUR
7. HEIGHT (m) 4'11
City/Municipality Province
8. WEIGHT (kg) 46 KG ZIP CODE 9700
18. PERMANENT ADDRESS 090 OLD CAPITOL
9. BLOOD TYPE o'
House/Block/Lot No. Street
MATAMPAY
10. GSIS ID NO. 02004784352
Subdivision/Village Barangay
MARAWI CITY LANAO DEL S
11. PAG-IBIG ID NO. 1211-5762-0640
City/Municipality Province
12. PHILHEALTH NO. 20-200016254-1 ZIP CODE 9700

13. SSS NO. N/A 19. TELEPHONE NO.

14. TIN NO. 447-51`0-671` 20. MOBILE NO. 091`97622`731`


15. AGENCY EMPLOYEE NO. Dep`ED -42`70505` 21. E-MAIL ADDRESS (if any) mirahatah@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/d
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME MAMARINTA


NAME EXTENSION (JR., SR)
FIRST NAME MIPANGCAT

MIDDLE NAME BATUAN

25. MOTHER'S MAIDEN NAME

SURNAME MACADAAG

FIRST NAME RINARIC

MIDDLE NAME MAMAYANDUG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND


HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/
26. PERIOD OF ATTENDANCE YEAR
UNITS
LEVEL (Write in full) EARNED
GRADUATED
(Write in full) (if not
From To
graduated)
ELEMENTARY MARAW CENT. ELEM. PILOT SCOOL ELEMENTARY GRADE 1`991` 1`996 1`996
VOCATIONAL / MSU- SAGUIARAN COMMUNITY
SECONDARY
COLLEGE SECONDARY 1`996
2`000 2`000

BACHELOR OF SCIENCE IN ELEMENTARY


COLLEGE TRADE MSU-MAIN CAMPUS 2`000 2`005 2`005
COURSE EDUCATIO
BUKIDNON STATE UNIVERSITY MASTER OF ARTS IN EDUCATIONAL
GRADUATE STUDIES
ILIGAN EXTERNAL STUDIES ADMINISTRATION
2`01`4 2`01`6 36 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), P
e/s against the

For CSC use only)

uralization

ry:

OL

OL

DEL SUR

RTH (mm/dd/yyyy)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
ed 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

PROFESSIONAL REGULATION COMISSION 76.6 CAGAYAN DE ORO CITY 1269457 11/23/2020

(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/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) MONTHLY PAY GRADE (if STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To (Y/
N)
DEPARTMENT OF EDUCATION REGULAR
4/27/2015 12/31/2015 TEACHER 1` 11-1 PERMANENT
DEPARTMENT OF EDUCATION REGULAR
1/1`/16 12/31/2016 TEACHER 1` 11-1 PERMANENT
DEPARTMENT OF EDUCATION REGULAR
1/1/2017 12/31/2018 TEACHER 1` 11-1 PERMANENT
DEPARTMENT OF EDUCATION REGULAR
1/1/2019 PRESENT TEACHER 1` 11-1 PERMANENT

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

(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
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION


MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)

(Continue on separate sheet if necessary)

SIGNATURE DATE
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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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
YES ✘ NO
regulation 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 If YES, give details:
phased 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 YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last 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
a.
items:
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
JAMIL PANDAPATAN OLD CAPITOL, MARAWI CITY 3.5 cm. X 4.5 cm
(passport size)

With full and handwritten


name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct or photocopied picture
is not acceptable
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 PHOTO
filing of 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.: 1269457


Signature (Sign inside the box)

Date/Place of Issuance: 1/7/2014


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 4