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 Caccam
NAME EXTENSION (JR., SR)
FIRST NAME Ivy Regine

MIDDLE NAME Buagas

3. DATE OF BIRTH
(mm/dd/yyyy) 3/26/1991 16. CITIZENSHIP

4. PLACE OF BIRTH Tagum City, Davao del norte If holder of dual citizenship, Filipino
please indicate the details.
5. SEX Female

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS Single
Block 7 Lot 47 Mabini street

Villa verde Subd. Barangay San Miguel

7. HEIGHT (m) 1.7
Tagum City Davao del Norte
8. WEIGHT (kg) 80 ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE A+
Block 7 Lot 47 Mabini street
10. GSIS ID NO. N/A
Villa verde Subd. Barangay San Miguel

11. PAG-IBIG ID NO. 121273661594

Tagum City Davao del Norte

12. PHILHEALTH NO. N/A ZIP CODE 8100

13. SSS NO. 0931668715 19. TELEPHONE NO.

14. TIN NO. N/A 20. MOBILE NO. 09928401715

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

II. FAMILY BACKGROUND

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

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME Caccam

NAME EXTENSION (JR., SR)
FIRST NAME Jonie

MIDDLE NAME Montejo

25. MOTHER'S MAIDEN NAME

SURNAME Buagas

FIRST NAME Shirley

MIDDLE NAME Pahinado (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 MAGUGPO PILOT IMELDA ELEMENTARY SCHOOL ELEMENTARY 1997 2003 GRADUATE 2003 N/A

SECONDARY /
VOCATIONAL SAINT MARY'S COLLEGE HIGHSCHOOL 2003 2007 GRADUATE 2007 N/A

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

TRADE
COURSE
COLLEGE UNIVERSITY OF MINDANAO BACHELOR OF ELEMENTRAY EDUCATION 2016 2021 GRADUATE 2021 N/A

GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE April 30, 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

Licensure Examination for Teachers 85.0 9/24/2023 TAGUM CITY 2183072 3/26/2027

(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)
NEWFOUNDLAND ARTS AND SCIENCE CONTRACT
8/1/2022 5/31/2023 ELEMENTARY TEACHER 9000.00 N/A N/A
ACADEMY OF TAGUM, INC. SERVICE

(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 30,2024

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

(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
CERTIFICATE OF PARTICIPATION CAPACITATING FUTURE TEACHERS IN THE
3/19/2021 3/19/2021 5 HOURS TECHNICAL PAFTE
NEW NORMAL
CERTIFICATE OF APPRECIATION EMPLOYERS' BEST PRACTICES AND
7/15/2021 7/15/2021 4 HOURS TECHNICAL UNIVERSITY OF MINDANAO
INTEGRITY OF RESILIENCE IN THE TIME OF PANDEMIC AND BEYOND
CERTIFICATE OF APPRECIATION CONTRIBUTION IN THE ACADEMY AS NEWFOUNDLAND ARTS AND SCIENCE
6/1/2022 4/23/2023 1 YEAR TECHNICAL
ELEMENTARY FACULTY ACADEMY OF TAGUM, INC.
NEWFOUNDLAND ARTS AND SCIENCE
CERTIFICATE OF PARTICIPATION SCHOOL-BASED BSP INVESTURE 2/3/2023 2/4/2023 48 HOURS SUPERVISORY
ACADEMY OF TAGUM, INC.

(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)

Excellent written and verbal communication skills N/A UM TAGUM ALUMNI ASSOCIATION INC.

Computer literate/MS Office N/A

Ability to work independently or as part of a team N/A

Can work without supervisions N/A

Highly organized and efficient N/A

Can do multitasking N/A

N/A
(Continue on separate sheet if necessary)

SIGNATURE DATE APRIL 30, 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?
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:
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
PROGRAM HEAD-BEED UM TAGUM the last 6 months
MONA LISA O. CHAGAS, LPT,MAED,PHD COLLEGE
9996824234 4.5 cm. X 3.5 cm
(passport size)
HIGH SCHOOL TEACHER CAMANLANGA
JOSHUA M. CABILLON, LPT NATIONAL HIGHSCHOOL
9300665567
SHS COORDINATOR AND GUIDANCE Computer generated
or photocopied picture
COUNSELOR NEWFOUNDLAND ARTS
RUBY AIMIE S. LEYRITA AND SCIENCE ACADEMY OF TAGUM,
9392127021 is not acceptable

42. INC.
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 administrative/criminal case/s against me.

PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of Issuance
Government Issued ID:

ID/License/Passport No.:
Signature (Sign inside the box)

Date/Place of Issuance:
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