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 VALLEDOR
NAME EXTENSION (JR., SR)
FIRST NAME MARK DARYL

MIDDLE NAME BACALTOS

3. DATE OF BIRTH
04/19/1997 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH SAN VICENTE, PALAWAN If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS N/A PUROK 4

Widowed House/Block/Lot No. Street

Separate
N/A ALIMANGUAN
Other/s: d
Subdivision/Village Barangay
SAN VICENTE PALAWAN
7. HEIGHT (m) 1.73
City/Municipality Province
8. WEIGHT (kg) 77 ZIP CODE 5309

18. PERMANENT ADDRESS N/A PUROK 4

9. BLOOD TYPE AB+
House/Block/Lot No. Street
N/A ALIMANGUAN
10. GSIS ID NO. 2005639025
Subdivision/Village Barangay
SAN VICENTE PALAWAN
11. PAG-IBIG ID NO. 121252036174
City/Municipality Province

12. PHILHEALTH NO. 092523400225 ZIP CODE 5309

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

14. TIN NO. 746-187-754-000 20. MOBILE NO. 0968-523-0148

15. AGENCY EMPLOYEE NO. 6023339 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 N/A
FIRST NAME N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME VALLEDOR

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

MIDDLE NAME NA AGAS

25. MOTHER'S MAIDEN NAME

SURNAME BACALTOS

FIRST NAME MARY JANE

MIDDLE NAME PAREDES (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

WITH
ELEMENTARY ALIMANGUAN ELEMENTARY SCHOOL PRIMARY EDUCATION 2004 2010 GRADUATED 2010
HONORS
WITH
SECONDARY /
VOCATIONAL ALIMANGUAN NATIONAL HIGH SCHOOL SECONDARY EDUCATION 2010 2014 GRADUATED 2014
HONORS
ASIAN BUSINESS CABLETOW COOPERATIVE FOOD AND BEVERAGE SERVICES NCII/ FRONT
ACADEMY OFFICE SERVICES NCII
2018 2018 COMPLETED 2018 N/A
TRADE
BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE WESTERN PHILIPPINES UNIVERSITY
MAJOR IN SOCIAL SCIENCE
2014 2018 GRADUATED 2018 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 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
(RA 1080) LICENSURE EXAMINATION FOR
80.80 September 30, 2018 PUERTO PRINCESA CITY, PALAWAN 1718078 04/19/2025
TEACHER (LET)

(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)

01/01/2023 06/29/23 TEACHER I DEPARTMENT OF EDUCATION P25, 439.00 11-1 PERMANENT Y

01/01/2022 12/31/2023 TEACHER I DEPARTMENT OF EDUCATION P25, 439.00 11-1 PERMANENT Y

01/01/2021 12/31/2021 TEACHER I DEPARTMENT OF EDUCATION P23, 877.00 11-1 PERMANENT Y

01/01/2020 12/31/2020 TEACHER I DEPARTMENT OF EDUCATION P22, 316.00 11-1 PERMANENT Y

06/17/2019 12/31/2019 TEACHER I DEPARTMENT OF EDUCATION P22, 316.00 11-1 PERMANENT Y

(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
ASIAN BUSINESS CABLETOW COOPERATIVE
FRONT OFFICE SERVICES NCII 05/01/2018 05/31/2018 442 SKILLS
ACADEMY
ASIAN BUSINESS CABLETOW COOPERATIVE
FOOD AND BEVERAGE SERVICES NCII 05/01/2018 05/31/2018 356 SKILLS
ACADEMY

SEMINAR ON PANDEMIC RESILIENT TEACHER FOR THE PROTECTION OF CHILDREN 12/13/2021 12/15/2021 24 MANAGERIAL DEPARTMENT OF EDUCATION

VIRTUAL IN-SERVICE TRAINING FOR TEACHERS 08/30/2021 09/03/2021 40 MANAGERIAL DEPARTMENT OF EDUCATION

VIRTUAL IN-SERVICE TRAINING FOR PUBLIC SCHOOL TEACHERS 03/15/2021 03/19/2021 40 MANAGERIAL DEPARTMENT OF EDUCATION

REGIONAL DISASTER RISK REDUCTION AND

NATIONAL DISASTER RESILIENCE MONTH (NDRM) 07/01/2021 07/01/2021 8 MANAGERIAL
MANAGEMENT COUNCIL
CAPACITY BUILDING FOR EPP/TLE/TVL TEACHER SEMINAR WORKSHOP ON TECHNICAL
08/23/2021 08/27/2021 32 MANAGERIAL DEPARTMENT OF EDUCATION
SKILLS
DE LA SALLE UNIVERSITY SOUTHEAST ASIA
INTERNATIONAL WEBINAR ON SOCIAL RESEARCH METHODS 10/27/2022 10/28/2022 16 MANAGERIAL
RESEARCH CENTER AND HUB

(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)

TABLE SETTING N/A N/A

PLAYING GUITAR

ELECTRICAL INSTALLATION

(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? YES ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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? Change of Agency
________________________________
________________________________
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
DARIO N. JAGMIS POBLACION, TAYTAY, PALAWAN 0948-194-6154 4.5 cm. X 3.5 cm
(passport size)

JOJIE T. CALIPAYAN SAN VICENTE, PALAWAN 0936-852-4295

Computer generated
or photocopied picture
ALLAN JAY D. GABUCO POBLACION, TAYTAY, PALAWAN 0967-7903-320 is not acceptable

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: PRC ID

ID/License/Passport No.: 1718078

Signature (Sign inside the box)

Date/Place of Issuance: 01/11/2019/ROBINSONS PALAWAN

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