CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misreppresentation 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 SAVELLANO

FIRST NAME MERCEDES NAME EXTENSION (JR., SR) N/A

MIDDLE NAME UBUAN

3. DATE OF BIRTH
(mm/dd/yyyy)
07/28/1980 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
✘ by naturalization
4. PLACE OF BIRTH SIGAY, ILOCOS SUR If holder of dual citizenship, Pls.birth
indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS N/A N/A

Widowed House/Block/Lot No. Street

Separated N/A LIPIT
Other/s:
Subdivision/Village Barangay
CABUGAO ILOCOS SUR
7. HEIGHT (m) 1.58
City/Municipality Province
8. WEIGHT (kg) 76 ZIP CODE 2732

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE O
House/Block/Lot No. Street
N/A LIPIT
10. GSIS ID NO. 2004544569
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 0031-3002-1903 CABUGAO ILOCOS SUR

City/Municipality Province

12. PHILHEALTH NO. 19-089490703-0 ZIP CODE 2732

13. SSS NO. 0001-1441436-2 19. TELEPHONE NO. N/A

14. TIN NO. 197-307-477 20. MOBILE NO. 0917 809 5922

15. AGENCY EMPLOYEE NO. 4201680 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME SAVELLANO 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME JUANITO DOMINIC JHON U. SAVELLANO 05/07/2010

MIDDLE NAME GARCIA

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME UBUAN

NAME EXTENSION (JR., SR) N/A
FIRST NAME MABINI

MIDDLE NAME COLOGAN

25. MOTHER'S MAIDEN NAME

SURNAME SINGUIPEN

FIRST NAME LUCREASIA

MIDDLE NAME GALANGEY (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 SIGAY CENTRAL SCHOOL ELEMENTARY 1988 1994 N/A 1983 N/A

SECONDARY /
VOCATIONAL SAN LUIS NATIONAL HIGH SCHOOL HIGH SCHOOL 1994 1998 N/A 1987 N/A

N/A N/A N/A N/A N/A N/A N/A

TRADE DIVINE WORD COLLEGE OF VIGAN (ST.
BACHELOR OF SCIENCE IN SECONDARY
COURSE
COLLEGE BENEDICT INSTITUTE)
EDUCATION
1998 2002 N/A 2002 N/A
MARYHILL SCHOOL OF THEOLOGY, QUEZON CITY
MASTER OF ARST IN RELIGIOUS STUDIES 2008 2012 30 UNITS N/A N/A
GRADUATE STUDIES
UNIVERSITY OF NORTHERN PHILIPPINES VIGAN
CITY
MASTER OF ARTS IN EDUCATION 2014 2017 30 UNITS N/A N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE 01/23/2020

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
75 9/25/2010 NATIONAL TEACHERS COLLEGE MANILA 1108934 12/19/2011
TEACHERS

(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)
DEPARTMENT OF EDUCATION DIVISION P25,232.00 REGULAR
01/01/2020 Present TEACHER III OF ILOCOS SUR 13-1 YES
PERMANENT
DEPARTMENT OF EDUCATION DIVISION
REGULAR
01/01/2019 12/31/2019 TEACHER I OF ILOCOS SUR P21,038 11-2 YES
PERMANENT
DEPARTMENT OF EDUCATION DIVISION
REGULAR
01/01/2018 12/31/2018 TEACHER I OF ILOCOS SUR P20,437 11-2 YES
PERMANENT
DEPARTMENT OF EDUCATION DIVISION
REGULAR
01/01/2017 12/31/2017 TEACHER I OF ILOCOS SUR P19,620 11-1 YES
PERMANENT
DEPARTMENT OF EDUCATION DIVISION
REGULAR
01/01/2016 12/31/2016 TEACHER I OF ILOCOS SUR P19,077 11-1 YES
PERMANENT
DEPARTMENT OF EDUCATION DIVISION
REGULAR
01/15/2014 12/31/2015 TEACHER I OF ILOCOS SUR P18,549 11-1 YES
PERMANENT
OUR LADY OF PEACE SCHOOL ANTIPOLO REGULAR
05/01/2009 03/31/2013 CLASSROOM TEACHER P14,230 N/A NO
CITY, RIZAL PERMANENT
ST. ANDREWS SCHOOL PARANAQUE CITY, REGULAR
05/01/2007 03/30/2009 CLASSROOM TEACHER P13,000 N/A NO
METRO MANILA PERMANENT
ST. VINCENT DE PAUL COLLGE BACOOR, REGULAR
05/01/2004 03/30/2007 CLASSROOM TEACHER P8,000 N/A NO
CAVITE PERMANENT

(Continue on separate sheet if necessary)

SIGNATURE DATE 01/23/2020

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

N/A N/A N/A N/A N/A

(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
REVISITING GAD KEY CONCEPTS AND SEMINAR IN INANCIAL LITERACY AND MANAGEMENT 12/13/2019 12/16/20 16 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
NSET (Training on Module Writing, Contextualiation, Budgetted Lesson and Action Research) 10/21/2019 10/23/2019 24 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
GENDER AND DEVELOPMENT SEMINAR: STRESS MANAGEMENT 12/17/2018 12/18/2018 18 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
NATIONAL DRUG EDUCATION PROGRAM (NDEP) AND ADOLESCENT REPRUDUCTIVE
DEPARTMENT OF EDUCATION
HEALTH (ARH) WITH THE THEME: "ACKNOWLEDGENG ADOLESCENT'S RISKY BEHAVIOUR : 12/10/2018 12/10/2018 8 Technical
DIVISION OF ILOCOS SUR
A STEM TOWARDS NATIONAL BUILDING"
DIVISION ENHANCEMENT TRAINING FOR ELEMENTARY AND SECONDARY EsP TEACHERS DEPARTMENT OF EDUCATION
11/7/2018 11/9/2018 24 Technical
ENGAGING THE HEART OF LEARNING DIVISION OF ILOCOS SUR

SIMULTANIOUS TEACHERS ORIENTATION ROLLOUT ON RESULT-BASED DEPARTMENT OF EDUCATION

10/26/2018 10/26/2018 8 Technical
PERORMANCE MANAGEMENT SYSTEM AND PPST DIVISION OF ILOCOS SUR

SEMINAR ON GENDER ISSUES AND SEX DISAGRAGATED DATA 12/07/2017 12/07/2017 8 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
SEMINAR WORKSHOP ON THE PREPARATION OF INSTRUCTIONAL MATERIALS 10/30/2017 10/30/2017 8 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
SCHOOL-BASE SEMINAR ON GENDER DEVELOPMENT 10/26/2017 10/26/2017 8 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
SEMINAR WORKSHOP ON TEST ANALYSIS 10/25/2017 10/25/2017 8 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
ROLLOUT ON BASIC GUIDANCE AND COUNSELING 10/24/2017 10/24/2017 8 Technical DEPED CABUGAO NATIONALHIGH SCHOOL
ENHANCEMENT TRAINING FOR ELEMNTARY AND SECONDARY SA DEPARTMENT OF EDUCATION
EDUKASYON SA PAGPAPAKATAO TEACHERS/UIDANCE COUNSELORS
08/25/2017 08/27/2017 24 Technical
DIVISION OF ILOCOS SUR

GENDER AWARENESS AND DEVELOPMENT TRAINING 12/14/2016 12/15/2016 16 Technical DEPARTMENT OF EDUCATION-CNHS

SPIRITUAL ENHANCEMENT TRAINING FOR ELEMENTARY AND SECONDARY EDUKASYON SA DEPARTMENT OF EDUCATION DIVISION
PAGPAPAKATAO (EsP) TEACHERS
11/2/2016 11/2/2016 8 Technical
OF ILOCOS SUR
DEPARTMENT OF EDUCATION DIVISION
TRAINING ON SPECIAL EDUCATION 12/12/2014 12/13/2014 16 Technical
OF ILOCOS SUR
DEPARTMENT OF EDUCATION
SEMINAR ON GENDER AWARENESS AND DEVELOPMENT 10/22/2014 10/24/1014 24 Technical
CABUGAO NATIONAL HIGH SCHOOL
NATIONAL SEMINAR ON ENHANCING GLOBAL TEACHING - INTEGRATING INSTRUCTIONAL
TECHNOLOGY -K TO 12
09/12/2014 09/14/2014 36 Technical PHILIPPINE NORMAL UNIVERSITY MANILA

DEPARTMENT OF EDUCATION
DIVISION ROLL-OUT ON POPULATION DEVELOPMENT EDUCATION (POPDEVED) 09/15/2014 09/15/2014 8 Technical
CABUGAO NATIONAL HIGH SCHOOL
DEPARTMENT OF EDUCATION
RPMS TRAINING 07/17/2014 07/19/2014 24 Technical
CABUGAO NATIONAL HIGH SCHOOL
REGIONAL MASS TRAINING OF GRADE 9 TEACHERS K TO 12 BASIC EDUCATION PROGRAM DEPARTMENT OF EDUCATION DIVISION
(EDUKASYON SA PAGPAPAKATAO)
05/12/2014 05/16/2014 40 Technical
OF ILOCOS SUR
DEPARTMENT OF EDUCATION DIVISION
DIVISION TRAINING WORKSHOP ROLL OUT ON CHILD PROTECTION POLICY 05/05/2014 05/07/2014 36 Technical
OF ILOCOS SUR
DEPARTMENT OF EDUCATION DIVISION
PAGSASANAY SA PANITIKAN AT PAGPAPAHALAGA GAMIT ANG MGA SERYE NG PAHINA 02/01/2014 02/01/2014 8 Technical
OF ILOCOS SUR

THEOLOGY REFRESHER COURSE ON THE YEAR OF FAITH 10/20/2012 10/21/2012 24 Technical ATENEO DE MANILA UNIVERSITY

ENGLISH PROFICIENCY TRAINING 05/31/2011 05/31/2011 8 Technical OUR LADY OF PEACE SCHOOL ANTIPOLO RIZAL

CONVERSATION SKILLS AND STRATEGIES 05/31/2011 05/31/2011 8 Technical OUR LADY OF PEACE SCHOOL ANTIPOLO RIZAL

LIVE PURE FORUM ON MORALITY AND CHASTITY 04/05/2011 04/05/2011 8 Technical OUR LADY OF PEACE SCHOOL ANTIPOLO RIZAL

ECHO SEMINAR ON THE LEARNING STRATEGIES, ASSESSMENT, AND THE GRADING

SYSTEM USING THE UNDERSTANDING BY DESIGN FRAMEWORK
04/29/2011 04/29/2011 8 Technical OUR LADY OF PEACE SCHOOL ANTIPOLO RIZAL

TEAM BUILDING SEMINAR ON UNDERSTANDING THE MODERATORS ROLE IN THE STUDENT

DEVELOPMENT
04/15/2011 04/15/2011 8 Technical OUR LADY OF PEACE SCHOOL ANTIPOLO RIZAL

(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)

COOKING N/A ILOCOS SUR TEACHERS ASSOCIATION

CABUGAO PUBLIC SCHOOL TEACHERS AND
RETIREES ASSOCIATION

(Continue on separate sheet if necessary)

SIGNATURE DATE 08/07/2019

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? ✘ NO
YES
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?
✘ NO
If YES,YES
give details: ________________________________
________________________________

b. Have you been criminally charged before any court? ✘ NO

YES
If YES, give details: ________________________________
________________________________
Date Filed:
Status of Case/s:

Have you ever been convicted of any crime or violation of any law, decree, ordinance or
36.
regulation by any court or tribunal? ✘ NO
If YES,YES
give details: ________________________________
________________________________

Have you ever been separated from the service in any of the following modes: resignation,
37.
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or ✘ NO
phased out (abolition) in the public or private sector?
YES
If YES, give details: ________________________________
________________________________
RESIGNATION

38. a. Have you ever been a candidate in a national or local election held within the last year
(except Barangay election)? ✘ NO
YES If YES, give details:

b. Have you resigned from the government service during the three (3)-month period before the ✘ NO
last election to promote/actively campaign for a national or local candidate? YES If YES, give details:

Have you acquired the status of an immigrant or permanent resident of another country?
39.
✘ NO
YES
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?
✘ NO
YES
If YES, please specify: BAG-O TRIBE
b. Are you a person with disability?
✘ NO
YES
If YES, please specify ID No:
c. Are you a solo parent?
✘ NO
YES
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
JONALYN S. RACILES TUROD, CABUGAO,ILOCOS SUR 0906 251 1846 3.5 cm. X 4.5 cm
(passport size)

ROCILYN S. SABATEN BACLIG,CABUGAO,ILOCOS SUR 0917 568 1906 With full and handwritten
name tag and signature over
BONIFACIO, CABUGAO, ILOCOS printed name
HILDA S. SAVELLA SUR
0917 800 7811
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.: 1108934

Signature (Sign inside the box)
01/23/2020
Date/Place of Issuance: 12/19/2011/ MANILA
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