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 against the 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 use only)

I. PERSONAL INFORMATION
2. SURNAME
CAPUNONG
FIRST NAME
CHRISTIAN N/A
MIDDLE NAME
ABEQUIBEL
3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy) ✘
11/6/1993
4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:
MALALAG, MAITUM SARANGANI PROVINCE
please indicate the details.
5. SEX ✘

6 CIVIL STATUS
✘ 17. RESIDENTIAL ADDRESS R. NOLASCO
House/Block/Lot No. Street
RAG-O MALALAG
Subdivision/Village Barangay
7. HEIGHT (m) MAITUM SARANGANI
1.68M City/Municipality Province
8. WEIGHT (kg) ZIP CODE
75kg 9515
9. BLOOD TYPE
18. PERMANENT ADDRESS R. NOLASCO
O+ House/Block/Lot No. Street

10. GSIS ID NO. RAG-O MALALAG

2005447817 Subdivision/Village Barangay

11. PAG-IBIG ID NO.

MAITUM SARANGANI
1212-2725-3133 City/Municipality Province

12. PHILHEALTH NO. ZIP CODE

172518841152 9515
13. SSS NO. 19. TELEPHONE NO.
N/A N/A
14. TIN NO. 20. MOBILE NO.
723-474-784 0948-380-9845
15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any)
4928923 [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
N/A
NAME EXTENSION (JR., SR)
FIRST NAME
N/A
MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME CAPUNONG

FIRST NAME LUDOVICO N/A

MIDDLE NAME ESCOSORA

25.MOTHER'S MAIDEN NAME

SURNAME ABEQUIBEL

FIRST NAME CONCHITA

MIDDLE NAME TIMBAL (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY MALALAG CENTRAL ELEMENTARY

SCHOOL ELEMENTARY 2000 2006 GRADUATED 2006 N/A

SECONDARY /
VOCATIONAL
MALALAG NATIONAL HIGH SCHOOL HIGH SCHOOL 2006 2010 GRADUATED 2010 N/A

N/A
TRADE
COURSE
COLLEGE EDENTON MISSION COLLEGE BACHELOR OF ELEMENTARY
INCORPORATED EDUCATION 2011 2016 GRADUATED 2016 N/A

GRADUATE STUDIES RAMON MAGSAYSAY MEMORIAL MASTER OF ARTS IN EDUCATION: MAJOR

COLLEGE IN EDUCATIONAL MANAGEMENT 2017 2018 18 UNITS N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE
FEBRUARY 26,2019
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 77.O 9/25/2016 DAVAO CITY 1493739 11/06/'19

(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 full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To DEPED SARANGANI : (Y/
REGULAR/
N)
Datal Basak IP Integrated PERMANEN
8/1/2018 PRESENT TEACHER 1 School 20, 179 SG-11 T Y
PERRET CENTRAL ELEMENTARY SUBSTITUT
6/5/2017 4/6/2018 RELIEVING TEACHER SCHOOL 0.00 N/A E Y

(Continue on separate sheet if necessary)

SIGNATURE DATE
FEBRUARY 26, 2019
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

MAITUM ELEMENTARY SCHOOL: NAT REVIEW FOR GRADE 6 4/24/2017 5/15/2017 120 HRS. VOLUNTEER TEACHER

SUMMER PRE-KINDERGATEN PROGRAM 4/25/2016 5/26/2016 120 HRS. VOLUNTEER TEACHER

(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/ CONDUCTE
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To
SPORTS TRAIMING AND SEMINAR WORKSHOP FOR COACHES AND DEPED SA
OFFICIATING OFFICIALS 11/8/2018 11/8/2018 25 HRS. PARTICIPANT PROVINCE
DEPED SA
DIVISION WIDE TEACHERS IDUCTION PROGRAM 10/29/2018 10/29/2018 8HRS PARTICIPANT HOTEL
DEPED M
DISTRICT ROLL OUT IN PPST AND RPMS 9/6/2018 9/7/2018 16HRS PARTICIPANT CENTRAL
DEPED RE
TEACHERS IDUCTION PROGRAM 8/30/2018 8/30/2018 8HRS PARTICIPANT CITY
DEPED M
BEGINNING READING SEMINAR-WAORKSHOP 7/12/2018 7/12/2018 8HRS PARTICIPANT CENTRAL
EAST WE
ETHICAL LEADERSHIP AND MANAGEMENT 6/2/2016 3/12/2016 24 HRS. PARTICIPANT NEW ERA
DISASTER AND CRISIS MANAGEMENT WITH PSYCHOLOGICAL FIRST AID EAST WE
AND EVACUATION CENTER MANAGEMENT 6/2/2016 3/12/2016 24 HRS. PARTICIPANT NEW ERA
 (Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

CHRUCH
COMPUTER LITERATE N/A IGLESIA
CHILDREN
TABLE TENNIS PRESIDEN
IGLESIA NI C
COMMUNICA
VOLLEYBALL INTERNATIO

BASKETBALL

ATHETICS

SINGING

(Continue on separate sheet if necessary)

SIGNATURE DATE
FEBRUA
T / PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

VOLUNTEER TEACHER

VOLUNTEER TEACHER

separate sheet if necessary)

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

CONDUCTED/ SPONSORED BY
(Write in full)

DEPED SARANGANI / KIAMBA SARANGANI

PROVINCE
DEPED SARANGANI / FAMILY COUNTRY
HOTEL
DEPED MAASIM 3 DISTRICT / MAASIM
CENTRAL ELEM. SCHOOL
DEPED REGION XII / KCC MALL GEN.SAN.
CITY
DEPED MAASIM 2 DISTRICT / SAN FELIPE
CENTRAL ELEM. SCHOOL
EAST WEST EDUCATIONAL SPECIALIST /
NEW ERA UNIVERSITY GEN. SAN. CITY
EAST WEST EDUCATIONAL SPECIALIST /
NEW ERA UNIVERSITY GEN. SAN. CITY
separate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
CHRUCH FINANCE OFFICER -
IGLESIA NI CRISTO
CHILDREN WORSHIP SERVICE
PRESIDENT - IGLESIA NI CRISTO
IGLESIA NI CRISTO SCAN MEMBER - SOCIETY OF
COMMUNICATORS AND NETWORKERS
INTERNATIONAL

separate sheet if necessary)

FEBRUARY 26, 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 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? ✘
b. within the fourth degree (for Local Government Unit - Career Employees)? ✘
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense? ✘
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? ✘
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
✘
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, ✘
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
✘
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
✘
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? ✘
If YES, please specify:
b. Are you a person with disability? ✘
If YES, please specify ID No:
c. Are you a solo parent? ✘
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
3.5 cm. X 4.5 cm
JOHNNY BANTULO MAASIM, SARANGANI PROVINCE 09271776132 (passport size)

With full and handwritten

KARLYNN AMBAG MAITUM, SARANGANI PROVINCE 09187269887 name tag and signature over
printed name
EDWARD RYAN GULAM MAASIM, SARANGANI PROVINCE 09124717150 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.: 1493739

Signature (Sign inside the box)
FEBRUARY 26, 2019
Date/Place of Issuance: GENERAL SANTOS CITY
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

IRMA MAY G. DINASAS, AO V

Person Administering Oath

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