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 GONZALES
NAME EXTENSION (JR., SR)
FIRST NAME AIZAH-MARIE N/A

MIDDLE NAME MUŇOZ

3. DATE OF BIRTH
8/9/1984 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
✘ by naturalization
birth
4. PLACE OF BIRTH MARIVELES BATAAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS 388 GUIHO

House/Block/Lot No. Street
Widowed
Separated ALION
Other/s: Subdivision/Village Barangay
7. HEIGHT (m) 1.57m MARIVELES BATAAN
City/Municipality Province
8. WEIGHT (kg) 63 kg ZIP CODE 2105

9. BLOOD TYPE A
18. PERMANENT ADDRESS BLK 2 BASINEA ALION
House/Block/Lot No. Street
10. GSIS ID NO. 2005997781 SITIO ILAYA ALION
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-6589-9183 MARIVELES BATAAN

City/Municipality Province

12. PHILHEALTH NO. 07-050445723-9 ZIP CODE 2105

13. SSS NO. 02-2184936-7 19. TELEPHONE NO. N/A

14. TIN NO. 944-410-877-000 20. MOBILE NO. 0966-864-6191

15. AGENCY EMPLOYEE NO. 5404908 21. E-MAIL ADDRESS (if any) [email protected] [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME GONZALES 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME ROLANDO N/A ALLIAH FRANCINNE M. GONZALES 2/9/2003
MIDDLE NAME VIDAL
OCCUPATION SHIP UNLOADER
EMPLOYER/BUSINESS NAME LIFT HIGH COMPANY

BUSINESS ADDRESS ST. ELENA, ORION, BATAAN

TELEPHONE NO. N/A
24. FATHER'S SURNAME MUŇO Z
NAME EXTENSION (JR., SR)
FIRST NAME NARCISO N/A

MIDDLE NAME YUMENA

25. MOTHER'S MAIDEN NAME SALCEDO
SURNAME MUŇOZ
FIRST NAME THELMA
MIDDLE NAME CELORICO (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 OLD ALION ELEMENTARY SCHOOL ELEMENTARY 3/6/1991 03/31/1997 GRADUATED 1997 VALEDICTORIAN
VOCATIONAL /
SECONDARY MNHS- CABCABEN SECONDARY 2/6/1997 03/31/2001 GRADUATED 2001 RANK 7

TESDA BARTENDING 10/21/2019 3/12/2019 GRADUATED 2019 N/A

BACHELOR IN ELEMENTARY SKOLAR NG
COLLEGE TRADE PUP-BATAAN BRANCH 06/13/2015 04/16/2019 GRADUATED 2019 BAYAN/1YR ACT-
COURSE EDUCATION CIS SCHOLAR
MASTER OF ARTS IN EDUCATIONAL
GRADUATE STUDIES BPSU GRADUATE SCHOOL MANAGEMENT
08/25/2021 8/1/2022 9 UNITS N/A N/A
CERTIFICATE PROGRAM IN EARLY CHILDHOOD
COLUMBAN COLLEGE, INC. EDUCATION (ECE)
08/08/2022 12/17/2022 18 UNITS 2023 N/A
(Continue on separate sheet if necessary)
SIGNATURE DATE March 8, 2024
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

LICENSED PROFESSIONAL TEACHER 82.4 09/29/2019 PAMPANGA NATIONAL HIGH SCHOOL 1865961 8/9/2023

(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 SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To
(Y/ N)

10/8/2022 9/5/2023 TEACHER 1 MT. VIEW ELEMENTARY SCHOOL 27000.00 SG-11/1 PERMANENT YES

01/17/2022 9/8/2022 TEACHER 1 IPAG ELEMENTARY SCHOOL 25439.00 SG-11/1 PERMANENT YES

O9/29/2021 11/24/2021 TEACHER 1 CABCABEN ELEMENTARY SCHOOL 23877.00 SG-11/1 SUBSTITUTE YES

06/16/2021 10/7/2021 TEACHER 1 SAINT FRANCIS ELEMENTARY SCHOOL 23877.00 SG-11/1 SUBSTITUTE YES

02/19/2021 05/30/2021 TEACHER 1 CABCABEN ELEMENTARY SCHOOL 23877.00 SG-11/1 SUBSTITUTE YES

10/11/2020 11/2/2021 TEACHER 1 SISIMAN ELEMENTARY SCHOOL 22316.00 SG-11/1 SUBSTITUTE YES

ASIA PACIFIC COLLEGE OF ADVANCED

2/5/2019 03/31/2020 PRESCHOOL TEACHER 10000.00 PROBATIONARY NO
STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE March 8, 2024
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

PPCRV 05/14/2009 PRESENT LOGISTICS, POLL CENTER COORDINATOR

(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

DIVISION SEMINAR-WORKSHOP IN KINDERGARTEN FOR UNTRAINED TEACHERS AND 9/8/2023 11/8/2023 24.0 TECHNICAL SDO-BATAAN
SCHOOL HEADS

CPD 3-DAY ONLINE INTERNATIONAL TRAINING VIRTUAL WORKSHOP ON READING 06/17/2022 06/19/2022 24.0 TECHNICAL SDO-BATAAN
TEACHING READING IN MOTHER-TONGUE AND BRIDGING PROCESS FOR GRADE 1
04/25/2022 04/26/2022 16.0 TECHNICAL
TEACHERS SDO-BATAAN
2020 WHOLE CHILD EDUCATION ROADSHOW: SUPPORTING & ENGAGING THE FILIPINO
11/1/2020 11/1/2020 8.0 TECHNICAL
WHOLE CHILD REX

NATIONAL CERTIFICATE II 10/21/2019 3/12/2019 326.0 TECHNICAL TESDA

EDUC-ACTION, MUSIC AND ARTS: INTEGRATION IN ELEMENTARY TEACHING 08/18/2017 08/18/2017 8.0 TECHNICAL PUP-BATAAN

INSTRUCTIONAL MATERIAL PREPARATION 11/3/2017 11/3/2017 8.0 TECHNICAL PUP-BATAAN

DIVISION SEMINAR-WORKSHOP IN SPORTS OFFICIATING AND COACHING 6/10/2016 8/10/2016 24.0 TECHNICAL
DIVISION OF BATAAN

(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 full)
(Write in full)

SINGING TEACHER VOLUNTEER IN NATIONAL READING CAMP 2023 CARD MUTUAL BENEFIT ASSOCIATION, INC.

MAPSTEA

(Continue on separate sheet if necessary)

SIGNATURE DATE March 8, 2024

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? END OF CONTRACT
________________________________
________________________________
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
JULIET B. BATALLONES BASECO, MARIVELES, BATAAN (0919) 0952 613 3.5 cm. X 4.5 cm
(passport size)

AILEEN R. NUŇEZ CABCABEN, MARIVELES, BATAAN (0966) 7697 239 With full and handwritten
name tag and signature over
printed name
MARICEL A. HUALDE CABCABEN, MARIVELES, BATAAN (0929) 8427 557
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

ID/License/Passport No.: 1865961

Signature (Sign inside the box)
March 8, 2024
Date/Place of Issuance: 09/08/2023 PRC Balanga City
Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this March 08, 2024 , affiant exhibiting his/her validly issued government ID as indicated above.

ELDA E. AFABLE
Person Administering Oath

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