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 BERGONIO
NAME EXTENSION (JR., SR)
FIRST NAME ANGELA

MIDDLE NAME CASER

3. DATE OF BIRTH
(mm/dd/yyyy) 2/23/1998 16. CITIZENSHIP
Filipino FILIPINO
Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH KABACAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male FEMALE Female

6 CIVIL STATUS Single SINGLE Married 17. RESIDENTIAL ADDRESS PUROK 4B

Widowed Separated House/Block/Lot No. Street
MALAMOTE
Other/s:
Subdivision/Village Barangay
KABACAN COTABATO
7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) 55 ZIP CODE 9407
18. PERMANENT ADDRESS PUROK 4B
9. BLOOD TYPE B+
House/Block/Lot No. Street
MALAMOTE
10. GSIS ID NO. N/A
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121260947706 KABACAN COTABATO

City/Municipality Province
12. PHILHEALTH NO. 17-250086771-5 ZIP CODE 9407

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

14. TIN NO. 755-963-723 20. MOBILE NO. 0909 419 2193

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A N/A

MIDDLE NAME N/A N/A N/A

OCCUPATION N/A N/A N/A

EMPLOYER/BUSINESS NAME N/A N/A N/A

BUSINESS ADDRESS N/A N/A N/A

TELEPHONE NO. N/A N/A N/A

24. FATHER'S SURNAME BERGONIO N/A N/A

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

MIDDLE NAME PERALTA N/A N/A

25. MOTHER'S MAIDEN NAME FLORIDA DELA CRUZ CASER N/A N/A

SURNAME BERGONIO N/A N/A

FIRST NAME FLORIDA N/A N/A

MIDDLE NAME CASER (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST
NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE LEVEL/ SCHOLARSHIP/
26. PERIOD OF ATTENDANCE YEAR
UNITS ACADEMIC
LEVEL (Write in full) EARNED
GRADUATED
HONORS
(Write in full) (if not RECEIVED
From To
graduated)
TACULEN-MALAMOTE ELEMENTARY
ELEMENTARY PRIMARY EDUCATION GRADUATED 2011 NA
SCHOOL
VOCATIONAL /
SECONDARY MALAMOTE HIGH SCHOOL SECONDARY EDUCATION GRADUATED 2015 NA

N/A N/A N/A NA NA

UNIVERSITY OF SOUTHERN BACHELOR OF SCIENCE IN AGRICULTURAL

COLLEGE TRADE 6/8/2019 GRADUATED 2019 NA
COURSE MINDANAO ECONOMICS

GRADUATE STUDIES N/A N/A N/A NA NA

(Continue on separate sheet if necessary)

SIGNATURE DATE
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
CAREER SERVICE PROFESSIONAL
80.69 8/20/2023 KIDAPAWAN CITY N/A N/A
EXAMINATION

(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/ SERVICE
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)
10/28/2019 3/20/2020 CASHIER SM ECOLAND DAVAO 15000.00 N/A FULLTIME NO

4/20/2021 5/23/2022 STOCK IN CHARGE GAISANO MALL KIDAPAWAN 13000.00 N/A FULLTIME NO

5/25/2022 PRESENT TELLER MLHUILLIER PAWNSHOP 15000.00 N/A FULLTIME NO

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

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

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

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

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

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

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

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
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)

(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)
PHILIPPINE AGRICULTURAL
COMPUTER LITERACY N/A ECONOMICS DEVELOPMENT
ASSOCIATION
TRANSACTION BALANCING N/A AGRICULTURAL ECONOMICS SOCIETY

CUSTOMER SERVICES N/A N/A

COOKING N/A N/A

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

(Continue on separate sheet if necessary)
SIGNATURE DATE
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? YESYES / NO
NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YESYES / NO
NO
If YES, give details: ________________________________

35. a. Have you ever been found guilty of any administrative offense? YESYES / NO
NO
If YES, give details: ________________________________
________________________________

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

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 YESYES / NO
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 YES / NONO
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 YESYES / NO 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? YESYES / NO NO
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons YES / NO
a. (RA 7277);
Are you and (c) of
a member Solo
anyParents Welfare
indigenous Act of 2000 (RA 8972), please answer the following
group? YES NO
items: 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
DONNA ERUALA SIJERA MIDSAYAP COTABATO 0946 316 0703 3.5 cm. X 4.5 cm
(passport size)

LADYMAER PASCUA REOVOCA KABACAN COTABATO 0910 556 2412 With full and handwritten
name tag and signature over
printed name
JOHNNY VALDEZ ROBLES KABACAN COTABATO 0976 018 0220
Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, or photocopied picture
is not acceptable
correct 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 PHOTO
attachments shall cause the 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: PASSPORT

ID/License/Passport No.: P6499167B

Signature (Sign inside the box)
03/20/2024
Date/Place of Issuance: 03/17/2021 DAVAO DFA
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