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 NERI
NAME EXTENSION (JR., SR)
FIRST NAME ROVAN

MIDDLE NAME TOM

3. DATE OF BIRTH
02/22/1997 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
✘ by birth by naturalization
4. PLACE OF BIRTH MANOLO FORTICH, BUKIDNON If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS ✘ Single Married

17. RESIDENTIAL ADDRESS ZONE 10 BOULEVARD
House/Block/Lot No. Street
Widowed Separated
N/A NATUMOLAN
Other/s:
Subdivision/Village Barangay
7. HEIGHT (m) 5 FEET, 7.5 INCHES TAGOLOAN MISAMIS ORIENTAL
City/Municipality Province
8. WEIGHT (kg) 63 KILOGRAMS ZIP CODE 9001

9. BLOOD TYPE A
18. PERMANENT ADDRESS ZONE 10 BOULEVARD
House/Block/Lot No. Street
10. GSIS ID NO. N/A N/A NATUMOLAN
Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A TAGOLOAN MISAMIS ORIENTAL

City/Municipality Province

12. PHILHEALTH NO. 15-251811584-1 ZIP CODE 9001

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

14. TIN NO. N/A 20. MOBILE NO. +639606255881 / +639604801034

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)

FIRST NAME N/A 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 NERI N/A N/A

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

MIDDLE NAME MALLARI N/A N/A

25. MOTHER'S MAIDEN NAME N/A N/A

SURNAME TOM N/A N/A

FIRST NAME EVANGELINE N/A N/A

MIDDLE NAME CATAGASAN (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

VICENTE N. CHAVES WITH

ELEMENTARY PRIMARY EDUCATION 9/6/2003 03/28/2008 GRADUATE 2008
MEMORIAL CENTRAL SCHOOL HONORS
FIRST
SECONDARY /
VOCATIONAL ST. MARY'S ACADEMY OF TAGOLOAN HIGH SCHOOL 9/6/2008 8/3/2012 GRADUATE 2012
HONOR

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

TRADE 2nd HONOR -
XAVIER UNIVERSITY – ATENEO DE BACHELOR OF SECONDARY EDUCATION
COURSE
COLLEGE 8/6/2015 03/21/2020 GRADUATE 2020 FIRST SEM
CAGAYAN (BSED) MAJOR IN VALUES EDUCATION SY 2018-19

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/27/2024

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

PROFESSIONAL TEACHER 87.6 3/19/2023 CAGAYAN DE ORO 2063423 02/22/2026

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 N/A

(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)
COMMUNITY ALS IMPLEMENTER (CAI) – ALTERNATIVE LEARNING SYSTEM (ALS) –
6/5/2020 PRESENT N/A N/A CONTRACTUAL Y
VOLUNTEER VILLANUEVA NORTH DISTRICT
HOME-BASED ONLINE ENGLISH
8/8/2019 10/19/2019 51TALK ENGLISH INTERNATIONAL, INC. P6,000 N/A CONTRACTUAL N
TEACHER
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

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

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/27/2024

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

ALTERNATIVE LEARNING SYSTEM (ALS) VILLANUEVA – NORTH DISTRICT 6/5/2020 PRESENT N/A COMMUNITY ALS IMPLEMENTER (CAI) – VOLUNTEER

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
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 WIDE IN-SERVICE TRAINING FOR ALTERNATIVE LEARNING SYSTEM DEPED ALTERNATIVE LEARNING SYSTEM
01/24/2023 01/30/2024 40 HOURS TECHNICAL
(ALS) IMPLEMENTERS (ALS)
10-DAY CAPACITY BUILDING FOR COMMUNITY ALTERNATIVE LEARNING DEPED ALTERNATIVE LEARNING SYSTEM
01/30/2023 10/2/2023 80 HOURS TECHNICAL
SYSTEM IMPLEMENTERS (CAIs) – VOLUNTEERS (ALS)
PLUMBING NC I 02/15/2022 03/23/2022 80 HOURS TECHNICAL TESDA – COBSAT
DIVISION-TRAINING OF TRAINING WORKSHOP FOR ALS, SPED, ALIVE, IPED & DEPED ALTERNATIVE LEARNING SYSTEM
02/15/2022 02/18/2022 32 HOURS TECHNICAL
ADM PROGRAM IMPLEMENTERS (ALS)
N/A N/A N/A N/A N/A N/A

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

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

(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)
PHILIPPINE ASSOCIATION FOR TEACHERS &
TOASTING N/A
EDUCATORS (PAFTE), INC.
READING N/A N/A

NET BROWSING N/A N/A

LISTENING TO MUSIC N/A N/A

COMPUTER SKILLS N/A N/A

N/A N/A N/A

N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 02/27/2024

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 ✘

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? ________________________________
________________________________
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: 10-4305-058-4167
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
REMEDIOS P. VIRADOR DAYAWAN, VILLANUEVA MIS. OR. 9659614531 4.5 cm. X 3.5 cm
(passport size)

PAULINA T. SABACAJAN KATIPUNAN, VILLANUEVA MIS. OR. 9922160582

Computer generated
or photocopied picture
HON. RAFAEL P. VIDAL NATUMOLAN, TAGOLOAN MIS. OR. N/A 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/License/Passport No.: 2063423 Signature (Sign inside the box)
02/27/2024
Date/Place of Issuance: 07/05/2023 / CAGAYAN DE ORO 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