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 EULATIC
NAME EXTENSION (JR., SR) JR
FIRST NAME PABLO

MIDDLE NAME LAURAS

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
12/20/1977 by birth by naturalizati
4. PLACE OF BIRTH BAGUMBAYAN, SULTAN KUDARAT If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

✘ Single Married 17. RESIDENTIAL ADDRESS N/A PUROK 5

6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
N/A GLAMANG
Other/s:
Subdivision/Village Barangay
POLOMOLOK SOUTH COTABATO
7. HEIGHT (m) 1.73
City/Municipality Province
8. WEIGHT (kg) 95 ZIP CODE 9504
18. PERMANENT ADDRESS N/A PUROK 5
9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. 02003473141

Subdivision/Village Barangay
POLOMOLOK SOUTH COTABATO
11. PAG-IBIG ID NO. 1890-0024-7954
City/Municipality Province
12. PHILHEALTH NO. 17-050116533 ZIP CODE 9504

13. SSS NO. NONE 19. TELEPHONE NO. NONE

14. TIN NO. 937-030-872 20. MOBILE NO. 09071790150

15. AGENCY EMPLOYEE NO. 4264686 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME NONE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/d
NAME EXTENSION (JR., SR) NONE
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME EULATIC

NAME EXTENSION (JR., SR) SR.
FIRST NAME PABLO

MIDDLE NAME LAGAÑA

25. MOTHER'S MAIDEN NAME

SURNAME LAURAS

FIRST NAME FLORITA

MIDDLE NAME SALDAU (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)
BAGUMBAYAN CENTRAL
ELEMENTARY
ELEMENTARY SCHOOL
ELEMENTARY 1985 1991 N/A 1991
VOCATIONAL / BAGUMBAYAN NATIONAL HIGH
SECONDARY
SCHOOL
HIGH SCHOOL 1991 1995 N/A 1995

NONE

TRADE MINDANAO STATE UNIVERSITY BACHELOR OF ARTS IN SOCIOLOGY 1995 1999 N/A 1999
COURSE
COLLEGE
 QUEZON COLLEGES OF
COLLEGE SOUTHERN PHILLIPINES
BACHELOR OF SECONDARY EDUCATION 2001 2001 18 UNITS 2001
DR. TAMONDONG MEMORIAL
SCHOOL
BACHELOR OF SCIENCE IN NURSING 2003 2006 N/A 2006
RAMON MAGSAYSAY MEMORIAL MASTER OF ARTS IN EDUCATION
COLLEGES MAJOR IN EDUCATION MANAGEMENT 2009 2011 N/A 2011
GRADUATE STUDIES
SULTAN KUDARAT STATE
UNIVERSITY
DOCTORS OF PHILOSOPHY 2009 PRESENT ÇAR N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 05/23/2019

CS FORM 212 (Revised 2017), P

e/s against the

For CSC use only)

JR

uralization

ry:

BATO

BATO

RTH (mm/dd/yyyy)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

1ST
HONOR
SALUTATORIAN

ENTRANCE
SCHOLAR
 NONE
FULL SHCOLAR

NONE

NONE

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
LICENSURE EXAMINATION FOR TEACHERS
75.0 8/26/2001 GENERAL SANTOS CITY 0727546 12/10/2001
(LET)
NATIONAL QUALIFYING EXAMINATION FOR
94.7 1/20/2013 KORONADAL CITY N/A 3/27/2013
SCHOOL HEAD
NURSES LICENSURE EXAMINATION 75.0 06/05-06/2016 DAVAO CITY 0884412 7/21/2016

(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)
DEPARTMEN OF EDUCATION-TUPI PERMANEN
2/10/2017 PRESENT SCHOOL PRINCIPAL-II 43250.00 20-1 Y
SOUTH T
DEPARTMENT OF EDUCATION- PERMANEN
9/26/2013 1/10/2017 SCHOOL PRINCIPAL-I 39685.00 19-02 Y
POLOMOLOK WEST T
DEPARTMENT OF EDUCATION-T'BOLI PERMANEN
7/2/2011 9/25/2013 HEAD TEACHER - I 23044.00 14-1 Y
EAST T
DEPARTMENT OF EDUCATION-T'BOLI PERMANEN
5/11/2007 6/30/2008 TEACHER - I 15900.00 11-2 Y
EAST T
DEPARTMENT OF EDUCATION- PERMANEN
3/6/2003 05/30/2007 TEACHER - I 7083.00 11-01 Y
ALABEL DISTRICT T

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/23/2019

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

NONE

(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)

THE ELT INTERNATIONAL SEMINAR WORKSHOP ËNHANCING AWARENESS AND SKILLS GLOBAL EDUCATORS NETWORK-TEFL,
ON THE WORLDS CURRENT TRENDS IN EDUCATION AND RESEARCH 7/28/2017 7/30/2017 24.0 TECHNICAL
THAILAND
SCHOOL HEADS DEVELOPMENT PROGRAM (SHDP) FOUNDATION COURSE MODULE 3 1/15/2017 1/22/2017 56.0 MANAGERIAL NEAP & DEPED REGIONAL OFFICE

SCHOOL HEADS DEVELOPMENT PROGRAM (SHDP) FOUNDATION COURSE MODULE 2 5/1/2017 11/1/2017 56.0 MANAGERIAL NEAP & DEPED REGIONAL OFFICE

SCHOOL HEADS DEVELOPMENT PROGRAM (SHDP) FOUNDATION COURSE MODULE 2 11/20/2016 11/26/2016 56.0 MANAGERIAL NEAP & DEPED REGIONAL OFFICE
DIVISION TRAINING ORIENTATION ON OMNIBUS POLICY ON KINDERGARTEN
EDUCATION 11/11/2016 11/11/2016 8.0 SUPERVISORY DEPED DIVISION OF SOUTH COTABATO

TEACH EXCELS 11/1/2016 2/22/2016 54.0 TECHNICAL SEAMEO INNOTECH

(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)
SINGING NONE NONE

DANCING

COMPUTER LITERATE

COOKING

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/23/2019

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
POLOMOLOK, SOUTH the last 6 months
LEVI B. BUTIHEN COTABATO
09295112398 3.5 cm. X 4.5 cm
(passport size)
POLOMOLOK, SOUTH
RAMONA F. BANGOC COTABATO
09282650226 With full and handwritten
name tag and signature over
printed name
CRISPIN A. SOLIVEN, JR. KORONADAL CITY 09082067288
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.: 0727546

Signature (Sign inside the box)
05/23/2019
Date/Place of Issuance: 10/12/2001
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