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 AMBOC

NAME EXTENSION (JR., SR) N/A

FIRST NAME JALAINE

MIDDLE NAME TAULAN

3. DATE OF BIRTH
1/7/1997 16. CITIZENSHIP
(mm/dd/yyyy)

4. PLACE OF BIRTH TABON QUEZON PALAWAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS N/A N/A

6 CIVIL STATUS
House/Block/Lot No. Street
N/A TABON
Subdivision/Village Barangay
QUEZON PALAWAN
7. HEIGHT (m) 1.524
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 5300

18. PERMANENT ADDRESS N/A N/A

9. BLOOD TYPE B
House/Block/Lot No. Street
N/A TABON
10. GSIS ID NO. N/A
Subdivision/Village Barangay
QUEZON PALAWAN
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. N/A ZIP CODE 5300

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

14. TIN NO. N/A 20. MOBILE NO. 09666404143

15. AGENCY EMPLOYEE NO. N/A 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) ZANE ASHRIEL A. ASUTILLA
FIRST NAME N/A 1/7/2020

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME AMBOC

NAME EXTENSION (JR., SR) JR
FIRST NAME JACINTO

MIDDLE NAME MAGBANUA

25. MOTHER'S MAIDEN NAME

SURNAME AMBOC

FIRST NAME NARCELITA

MIDDLE NAME TAULAN (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
(Write in full) HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY TABON ELEMENTARY SCHOOL ELEMENTARY 2004 2010 N/A 2010 N/A

SECONDARY /
VOCATIONAL QUEZON NATIONAL HIGHSCHOOL HIGH SCHOOL 2010 2014 N/A 2024 N/A

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

TRADE
COURSE
COLLEGE WESTERN PHILIPPINES UNIVERSITY BACHELOR OF ELEMENTARY EDUCATION 2014 2020 N/A 2020 N/A

GRADUATE STUDIES 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 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE
Validity

PROFESSIONAL LICENSURE EXAMINATION FOR TEACHER 88 PALAWAN NATIONAL HIGHSCHOOL 2039986 1/7/2026

NOTHING FOLLOWS

(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 GRADE (if
(mm/dd/yyyy) DEPARTMENT / AGENCY / OFFICE / MONTHLY STATUS OF
(Write in full/Do not SALARY
applicable)& STEP
APPOINTMENT
COMPANY (Write in dull/Do not abbreviate) (Format "00-0")/
abbreviate) INCREMENT
From To
(Y/ N)
CONTRACT OF
3/23/2022 4/22/2023 TEACHER EL MONTESSORI ERD SCHOOL 8000 N/A SERVICE
N

NOTHING FOLLOWS

(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
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
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

COMPUTER LITERACY PROGRAM NATIONAL CERTIFICATE II 03/27/2023 04/21/2023 120 TECHNICAL DIVINE GRACE INSTITUTE

NOTHING FOLLOWS

(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)

ARTS AND CRAFTS N/A N/A

COOKING

TRAVELLING

GARDENING

READING

NOTHING FOLLOWS

(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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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
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,
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
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
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?
If YES, please specify: PALAW'AN
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
4.5 cm. X 3.5 cm
MARCIAL M. ASUTILLA PUERTO PRINCESA CITY PALAWAN N/A (passport size)

ROSE A. MAQUILING ISUGOD QUEZON PALAWAN N/A Computer generated

or photocopied picture
is not acceptable
BABY JANE A. BERNALES NARRA PALAWAN N/A

42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, 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 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: PROFESSIONAL REGULATION COMMISION

ID/License/Passport No.: 2039986

Signature (Sign inside the box)

Date/Place of Issuance: 05/02/2023

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