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 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 CUIS
NAME EXTENSION (JR., SR)
FIRST NAME LEO SANDY

MIDDLE NAME AMBE

3. DATE OF BIRTH
(mm/dd/yyyy) 11 19 1999 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH ALLEN NORTHERN SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 438 16TH
Widowed Separated House/Block/Lot No. Street
OUR LADY'S VILLAGE PANGPANG
Other/s:
Subdivision/Village Barangay
SORSOGON CITY SORSOGON
7. HEIGHT (m) 5'6"
City/Municipality Province
8. WEIGHT (kg) 67 KILOGRAMS ZIP CODE 4700

18. PERMANENT ADDRESS 438 16TH

9. BLOOD TYPE B
House No. Street
OUR LADY'S VILLAGE PANGPANG
10. GSIS ID NO. BP #2004997308
Subdivision/Village Barangay
SORSOGON CITY SORSOGON
11. PAG-IBIG ID NO. 1211 - 6891- 4435
City/Municipality Province

12. PHILHEALTH NO. 10 - 050161536 - 0 ZIP CODE 4700

13. SSS NO. 05 - 1031349 - 4 19. TELEPHONE NO. NOT APPLICABLE

14. TIN NO. 413 - 192 - 804 20. MOBILE NO. 09297046531

15. AGENCY EMPLOYEE NO. 5812642 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NOT APPLICABLE 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE

MIDDLE NAME NOT APPLICABLE

OCCUPATION NOT APPLICABLE

EMPLOYER/BUSINESS NAME NOT APPLICABLE

BUSINESS ADDRESS NOT APPLICABLE

TELEPHONE NO. NOT APPLICABLE

24. FATHER'S SURNAME CUIS

NAME EXTENSION (JR., SR)
FIRST NAME LEO SANDY

MIDDLE NAME GALIDO

25. MOTHER'S MAIDEN NAME

SURNAME AMBE

FIRST NAME LIAN

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

MARCH MARCH
ELEMENTARY VICTORIA CENTRAL ELEMENTARY SCHOOL PRIMARY 6/1/1992
1997
Graduated N/A
1997
MARCH,
SECONDARY
VOCATIONAL / SORSOGON NATIONAL HIGH SCHOOL HIGH SCHOOL JUNE1997
2001
Graduated Mar-01 N/A

NOT APPLICABLE NOT APPLICABLE N/A N/A N/A N/A N/A

TRADE
COURSE
COLLEGE NOT APPLICABLE NOT APPLICABLE JUNE,2001 APRIL, 2001 Graduated APRIL, 2001 N/A

COMPLETE
NOVEMBE OCTOBER,
GRADUATE STUDIES NOT APPLICABLE NOT APPLICABLE R, 2009 2015
ACADEMIC N/A N/A
REQUIREMENT

(Continue on separate sheet if necessary)

SIGNATURE DATE July 30, 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 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 9/28/2008 AQUINAS UNIVERSITY OF LEGAZPI 1000676 6/30/2021

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
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
(Y/ N)

6/5/2017 PRESENT TEACHER II - SHS DepEd. Sorsogon National High School 22, 149 SG - 12 Reg./ Per. Yes

5/30/2016 05/26/20017 TEACHER II - SHS DepEd Buenavista National High School 20, 651 SG - 12 Reg./ Per. Yes
ST. LOUISE DE MARILLAC COLLEGE OF
6/1/2012 3/30/2016 COLLEGE INSTRUCTOR 10, 900 N/A Reg./ Per. No
SORSOGON
02/15/2011 11/30/2011 PRESCHOOL/ GRADE SCHOOL TEACHER WASHINGTON INTERNATIONAL SCHOOL 9, 500 N/A Regular No
BICOL UNIVERSITY COLLEGE OF ARTS
6/15/2011 10/15/2011 COLLEGE INSTRUCTOR 1, 512 N/A Part Time Yes
AND SCIENCES
 (Continue on separate sheet if necessary)

SIGNATURE DATE July 30, 2018

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 / NATURE OF WORK
From To

NOT APPLICABLE N/A N/A N/A NOT APPLICABLE G

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

Cluster - Based Learning Action Cell - SHS 7/21/2017 3/12/2018 56.0 Technical Sorsogon City Division Office

Division INSET for Secondary Teachers (Senior High School) 10/26/2017 10/27/2017 16.0 Technical Sorsogon City Division Office

In - Service Training of Senior High School Teachers 10/23/2017 10/25/2017 24.0 Technical DepEd Sorsogon National High School

Division In - Service Training for Teachers 10/24/2016 10/26/2016 24.0 Technical Sorsogon City Division Office

Walkthrough of the Senior High School Curriculum and Pedagogy 8/13/2016 8/27/2016 24.0 Technical Sorsogon City Division Office

Conduct of the Regional Senior High School (SHS) Mass Training of Grade 11 Teachers on
6/27/2016 7/30/2016 144.0 Technical Department pf Education Regional Office
Academic Track (Batch 2)
Conduct of the Regional Senior High School (SHS) Mass Training of Grade 11 Teachers on
06/14/2016 06/17/2016 32.0 Technical Department pf Education Regional Office
Common Topics (Batch 2)

Seminar Workshop on Homeroom Guidance Program 2/29/2012 02/30/2012 16.0 Technical St. Louise de Marillac College of Sorsogon

Reagional Training of Teachers for Grade 1 and 7 of the K - 12 Basic Education Curriculum 7/16/2012 7/20/2012 40.0 Technical Bicol University College of Education

ASD - ADHD: An Early Detection and Early Intervention Seminar 10/5/2011 10/5/2011 8.0 Technical Divine Word College of Legazpi

JFK Center Foundation and Divine Word College of

Divine Word College of Legazpi - JFK 80 Hour VOCCBELL Training Program 7/30/2006 8/11/2006 80.0 Technical
Legazpi

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Basic Computer Skills SNHS Faculty and Personnel Organization

Directing plays

(Continue on separate sheet if necessary)

SIGNATURE DATE July 30, 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 ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? ________________________________
Resignation
________________________________
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
CP# the last 6 months
Teresita N. Borromeo Burabod Sorsogon City
09994820779 3.5 cm. X 4.5 cm
(passport size)

Engr. Nardito L. Mediana Jr. Mayon, Castilla, Sorsogon 09359794303 With full and handwritten
name tag and signature over
printed name
Heide B. Docog San Roque Bacon District Sorsogon City 09088932195
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: TIN: 413 - 192 - 804 - 000
KIARA LYKA LL. ESPINOSA
ID/License/Passport No.:
Signature (Sign inside the box)
July 30, 2018
Date/Place of Issuance: May 30, 2012
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