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 GARCIA
NAME EXTENSION (JR., SR)
FIRST NAME IMELDA

MIDDLE NAME DE GUZMAN

3. DATE OF BIRTH
3/14/1969 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘
by by
birth naturalization
4. PLACE OF BIRTH BAYAMBANG, PANGASINAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS #303 BUAYAEN
Widowe Separat House/Block/Lot No. Street

d ed
Other/s: Subdivision/Village Barangay
7. HEIGHT (m) 1.75 m BAYAMBANG PANGASINAN
City/Municipality Province
8. WEIGHT (kg) ZIP CODE 2423
59 kg.
18. PERMANENT ADDRESS #303 BUAYAEN
9. BLOOD TYPE O
House/Block/Lot No. Street

10. GSIS ID NO. 69031401186

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 128000411554 BAYAMBANG PANGASINAN

City/Municipality Province

12. PHILHEALTH NO. 19-000280348-1 ZIP CODE 2423

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

14. TIN NO. 171-546-673 20. MOBILE NO. 09193950479

15. AGENCY EMPLOYEE NO. 4114275 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GARCIA 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) HEINNA ALYSSA D. GARCIA
FIRST NAME SAMUEL 11/5/1997

MIDDLE NAME TORRES OLIVER ROY D. GARCIA 8/13/1998

OCCUPATION SEAMAN SAMIELLE ALEXIS D. GARCIA 12/21/2000

EMPLOYER/BUSINESS NAME JEBSEN MARITIME INC.

BUSINESS ADDRESS PORT AREA MANILA

TELEPHONE NO. N/A

24. FATHER'S SURNAME DE GUZMAN

NAME EXTENSION (JR., SR)
FIRST NAME RUPERTO

MIDDLE NAME RAMOS

25. MOTHER'S MAIDEN NAME

SURNAME BUHAY

FIRST NAME LORETA

MIDDLE NAME DE GUZMAN (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY BAYAMBANG CENTRAL SCHOOL PRIMARY EDUCATION 1976 1981 GRADUATE 1981 NONE

SECONDARY /
VOCATIONAL BAYAMBANG NATIONAL HIGH SCHOOL HIGH SCHOOL 1981 1985 GRADUATE 1985 NONE

NA NA NA NA NA NA NA
TRADE
COURSE PANGASINAN STATE UNIVERSITY COLLEGE OF
COLLEGE
EDUCATION
BACHELOR IN ELEMENTARY EDUCATION 1985 1989 GRADUATE 1989 NONE

PANGASINAN STATE UNIVERSITY

GRADUATE STUDIES MASTER OF ARTS IN EDUCATION 1989 1991 27 UNITS NA NONE
COLLEGE OF EDUCATION
(Continue on separate sheet if necessary)

SIGNATURE DATE 05/04/2018 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
PROFESSIONAL BOARD EXAMINATION FOR
81.60 8/23/1997 BAGUIO CITY 0455245 10/28/1997
TEACHERS

PROFESSIONAL CIVIL SERVICE ELIGIBILITY 82.2 7/21/2002 URDANETA CITY 008345 8/15/2002

(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 applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) SALARY (Format "00-0")/
INCREMENT
From To
(Y/ N)
DEPARTMENT OF EDUCATION/ PANGASINAN I/
01/01/2018 PRESENT TEACHER III BAYAMBANG CENTRAL SCHOOL
P24047 13-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
1/1/2017 12/31/2017 TEACHER III BAYAMBANG CENTRAL SCHOOL
P23257 13-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
1/1/2016 12/31/2016 TEACHER III BAYAMBANG CENTRAL SCHOOL
P21436 13-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
11/19/2012 12/31/2016 TEACHER III BAYAMBANG CENTRAL SCHOOL
P19291 13-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
6/24/2010 11/18/2012 TEACHER II BAYAMBANG CENTRAL SCHOOL
P17833 13-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
08/01/2009 06/23/2010 TEACHER II BAYAMBANG CENTRAL SCHOOL
P15733 11-2 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
7/1/2008 07/30/2009 TEACHER II BAYAMBANG CENTRAL SCHOOL
P13392 11-2 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
7/11/2007 06/30/2008 TEACHER II BAYAMBANG CENTRAL SCHOOL
P12175 11-2 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
7/1/2007 02/10/2008 TEACHER II BAYAMBANG CENTRAL SCHOOL
P11589 11-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
11/15/2005 06/30/2007 TEACHER II BAYAMBANG CENTRAL SCHOOL
P11068 11-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
11/15/2002 11/14/2005 TEACHER II BAYAMBANG CENTRAL SCHOOL
P10854 11-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
1/1/2000 11/14/2002 TEACHER II BAYAMBANG CENTRAL SCHOOL
P10541 10-2 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
11/15/1999 12/31/1999 TEACHER II BAYAMBANG CENTRAL SCHOOL
P9349 10-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
11/1/1997 11/14/1999 TEACHER II BAYAMBANG CENTRAL SCHOOL
P9121 10-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
1/1/1997 10/31/1997 TEACHER II BAYAMBANG CENTRAL SCHOOL
P7682 10-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
11/15/1996 12/31/1996 TEACHER II BAYAMBANG CENTRAL SCHOOL
P6243 10-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
1/1/1996 11/04/1996 TEACHER II BAYAMBANG CENTRAL SCHOOL
P6013 10-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
1/1/1995 12/31/1995 TEACHER II BAYAMBANG CENTRAL SCHOOL
P4902 10-1 PERMANENT Yes
DEPARTMENT OF EDUCATION/ PANGASINAN I/
6/20/1994 12/31/1994 TEACHER I BAYAMBANG CENTRAL SCHOOL
P3902 10-1 PERMANENT Yes

6/12/1989 03/26/1994 CLASSROOM TEACHER ST. JOHN'S CATHEDRAL SCHOOL, DAGUPAN CITY P2791 CONTRACTUAL No

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/04/2018 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

NA NA NA NA NA
(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. CONDUCTED/ SPONSORED BY
TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS (Write in full) NUMBER OF HOURS ( Managerial/ Supervisory/
(mm/dd/yyyy) Technical/etc) (Write in full)

From To

DISTRICT LAC SESSION IN ENGLISH 11/2/2017 8 ACADEMICS DEPARTMENT OF EDUCATION

ORIENTATION -WORKSHOP ON CHANGING SCHOOL CULTURE THROUGH CHARACTER AND
10/29/2017 8 ACADEMICS DEPARTMENT OF EDUCATION
CREATIVITY INITIATIVE (CCI)
PATROL LEADER TRAINING COURSE 9/1/2017 9/3/2017 24 TECHNICAL DEPARTMENT OF EDUCATION

GENDER AND DEVELOPMENT DISTRICT SEMINAR 5/31/2017 6/2/2017 24 MANAGERIAL DEPARTMENT OF EDUCATION

DIVISION MASS TRAINING OF GRADE 6 TEACHERS ON K TO 12 BASIC EDUCATION 5/5/2017 5/11/2017 56 MANAGERIAL DEPARTMENT OF EDUCATION
CURICULUM
GENDER AND DEVELOPMENT DISTRICT SEMINAR 5/17/2016 5/19/2017 24 MANAGERIAL DEPARTMENT OF EDUCATION

GENDER AND DEVELOPMENT ANCHORED ON PUBLIC ACCOUNTABILITY AND VALUE 5/6/2016 5/19/2016 24 MANAGERIAL DEPARTMENT OF EDUCATION
ENHANCEMENT
CHILD INJURY PREVENTION PROGRAM 9/28/2012 8 TECHNICAL DEPARTMENT OF EDUCATION
DISTRICT LAC SESSION IN CHARACTER EDUCATION 01/06/2012 8 ACADEMICS DEPARTMENT OF EDUCATION

DISTRICT GAD SEMINAR 9/29/2011 10/01/2011 24 MANAGERIAL DEPARTMENT OF EDUCATION

DISTRICT LAC SESSION IN ENGLISH 11/29/2011 8 ACADEMICS DEPARTMENT OF EDUCATION

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 05/04/2018 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:

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

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
DR. CATHERIND D. FERRER CALASIAO, PANGASINAN 9991579472 3.5 cm. X 4.5 cm
(passport size)

DR. SHERLITA F. BARATANG BAYAMBANG, PANGASINAN 9185963648 With full and handwritten
name tag and signature over
printed name
DR. CANDRA E. PENOLIAR MALASIQUI, PANGASINAN 9988577125
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and complete statement or photocopied picture
is not acceptable
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 administrative/criminal case/s against me.
PHOTO

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.: 1010658

Signature (Sign inside the box)

Date/Place of Issuance: LINGAYEN/06-08-92

05/04/2018
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